基于FHIR标准的健康档案共享文档实施指南
0.8.0.2022705 - 持续集成版

基于FHIR的健康档案共享文档实施时必须严格遵循本实施指南的规定。

Resource Profile: 转诊申请结构定义

Defining URL:http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-referral-request
Version:0.8.0.2022705
Name:ReferralRequest
Title:转诊申请结构定义
Status:Active as of 2022-07-05T13:46:42+08:00
Definition:

转诊申请资源本地化定义。

Publisher:CHIMA&HL7中国委员会
Source Resource:XML / JSON / Turtle

转诊申请结构定义的正式唯一标识为:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-referral-request

简介

随访服务使用 Encounter 资源进行表示。该资源的本地化结构定义声明了对适用于健康医疗信息平台中随访服务的最低要求。它确定在使用此资源时应包含哪些核心元素、扩展和术语。

转诊申请使用 ServiceRequest 资源进行表示。该资源的本地化结构定义声明了对适用于健康医疗信息平台中转诊申请的最低要求。它确定在使用此资源时应包含哪些核心元素、扩展和术语。

快速实施指导

转诊意向(intent)根据具体情况,可以选择使用编码 proposal(提议)、plan(计划)、direct(直接)、order(医嘱)。例如,在随访活动中,随访医师发现慢病患者需要转诊治疗,在不紧急的情况下,可以进行提议(proposal),如果情况紧急,随访医师直接(direct)现场帮助患者进行转诊申请。

申请人(requester)指向提出本次转诊申请的医师。例如,在随访活动中,如果随访医师发现慢病患者需要进行转诊,则本次转诊申请的申请人就是随访医师。

接收机构和科室使用performer元素记录。接收科室会关联接收机构。

reasonCode元素用于记录编码型的转诊原因。但是转诊原因如果是用文本进行描述时,可以将文本记录在reasonCode.text元素中。

定义内容的视图

转诊申请结构定义是在FHIR标准的ServiceRequest基础上进行更加详细的规则约束,下表展示了转诊申请结构定义的结构表示。

关于定义、差异、快照以及如何解读这些表示法

这种结构源自 ServiceRequest

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ServiceRequest.performer is sliced based on the value of profile:.

这种结构源自 ServiceRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest 0..*ServiceRequestA request for a service to be performed
... status 1..1code服务请求的状态,默认值可以设为active
... intent 1..1code请求目的
... code 1..1CodeableConceptWhat is being requested/ordered
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 3457005
..... display1..1stringRepresentation defined by the system
Fixed Value: 转诊
... encounter 1..1Reference(Encounter)指向转诊申请所属的诊疗活动资源,例如:随访活动
... authoredOn 1..1dateTime转诊请求时间
... requester 1..1Reference(卫生服务人员信息结构定义)指向转诊申请医师的引用
... performer 2..*(Slice Definition)Requested performer
Slice: Unordered, Open by profile:.
.... performer:Department 1..1Reference(科室信息结构定义)转入科室
.... performer:Hospital 1..1Reference(医疗机构结构定义)转入机构
... reasonCode 0..1CodeableConcept转诊原因

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest I0..*ServiceRequestA request for a service to be performed
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierIdentifiers assigned to this order
... instantiatesCanonical Σ0..*canonical(ActivityDefinition | PlanDefinition)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest | MedicationRequest)What request fulfills
... replaces Σ0..*Reference(ServiceRequest)What request replaces
... requisition Σ0..1IdentifierComposite Request ID
... status ?!Σ1..1code服务请求的状态,默认值可以设为active
Binding: RequestStatus (required): The status of a service order.

... intent ?!Σ1..1code请求目的
Binding: RequestIntent (required): The kind of service request.

... category Σ0..*CodeableConceptClassification of service
Binding: ServiceRequestCategoryCodes (example): Classification of the requested service.


... priority Σ0..1coderoutine | urgent | asap | stat
Binding: RequestPriority (required): Identifies the level of importance to be assigned to actioning the request.

... doNotPerform ?!Σ0..1booleanTrue if service/procedure should not be performed
... code Σ1..1CodeableConceptWhat is being requested/ordered
Binding: ProcedureCodes(SNOMEDCT) (example): Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available here.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 3457005
..... display1..1stringRepresentation defined by the system
Fixed Value: 转诊
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... orderDetail ΣI0..*CodeableConceptAdditional order information
Binding: ServiceRequestOrderDetailsCodes (example): Codified order entry details which are based on order context.


... quantity[x] Σ0..1Service amount
.... quantityQuantityQuantity
.... quantityRatioRatio
.... quantityRangeRange
... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ1..1Reference(Encounter)指向转诊申请所属的诊疗活动资源,例如:随访活动
... occurrence[x] Σ0..1When service should occur
.... occurrenceDateTimedateTime
.... occurrencePeriodPeriod
.... occurrenceTimingTiming
... asNeeded[x] Σ0..1Preconditions for service
Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc.

.... asNeededBooleanboolean
.... asNeededCodeableConceptCodeableConcept
... authoredOn Σ1..1dateTime转诊请求时间
... requester Σ1..1Reference(卫生服务人员信息结构定义)指向转诊申请医师的引用
... performerType Σ0..1CodeableConceptPerformer role
Binding: ParticipantRoles (example): Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc.

... performer Σ2..*(Slice Definition)Requested performer
Slice: Unordered, Open by profile:.
.... performer:Department Σ1..1Reference(科室信息结构定义)转入科室
.... performer:Hospital Σ1..1Reference(医疗机构结构定义)转入机构
... locationCode Σ0..*CodeableConceptRequested location
Binding: ServiceDeliveryLocationRoleType (example): A location type where services are delivered.


... locationReference Σ0..*Reference(Location)Requested location
... reasonCode Σ0..1CodeableConcept转诊原因
Binding: ProcedureReasonCodes (example): Diagnosis or problem codes justifying the reason for requesting the service investigation.


... reasonReference Σ0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Explanation/Justification for service or service
... insurance 0..*Reference(Coverage | ClaimResponse)Associated insurance coverage
... supportingInfo 0..*Reference(Resource)Additional clinical information
... specimen Σ0..*Reference(Specimen)Procedure Samples
... bodySite Σ0..*CodeableConceptLocation on Body
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... note 0..*AnnotationComments
... patientInstruction Σ0..1stringPatient or consumer-oriented instructions
... relevantHistory 0..*Reference(Provenance)Request provenance

doco Documentation for this format

这种结构源自 ServiceRequest

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ServiceRequest.performer is sliced based on the value of profile:.

差异视图

这种结构源自 ServiceRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest 0..*ServiceRequestA request for a service to be performed
... status 1..1code服务请求的状态,默认值可以设为active
... intent 1..1code请求目的
... code 1..1CodeableConceptWhat is being requested/ordered
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 3457005
..... display1..1stringRepresentation defined by the system
Fixed Value: 转诊
... encounter 1..1Reference(Encounter)指向转诊申请所属的诊疗活动资源,例如:随访活动
... authoredOn 1..1dateTime转诊请求时间
... requester 1..1Reference(卫生服务人员信息结构定义)指向转诊申请医师的引用
... performer 2..*(Slice Definition)Requested performer
Slice: Unordered, Open by profile:.
.... performer:Department 1..1Reference(科室信息结构定义)转入科室
.... performer:Hospital 1..1Reference(医疗机构结构定义)转入机构
... reasonCode 0..1CodeableConcept转诊原因

doco Documentation for this format

快照视图

NameFlagsCard.TypeDescription & Constraintsdoco
.. ServiceRequest I0..*ServiceRequestA request for a service to be performed
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierIdentifiers assigned to this order
... instantiatesCanonical Σ0..*canonical(ActivityDefinition | PlanDefinition)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest | MedicationRequest)What request fulfills
... replaces Σ0..*Reference(ServiceRequest)What request replaces
... requisition Σ0..1IdentifierComposite Request ID
... status ?!Σ1..1code服务请求的状态,默认值可以设为active
Binding: RequestStatus (required): The status of a service order.

... intent ?!Σ1..1code请求目的
Binding: RequestIntent (required): The kind of service request.

... category Σ0..*CodeableConceptClassification of service
Binding: ServiceRequestCategoryCodes (example): Classification of the requested service.


... priority Σ0..1coderoutine | urgent | asap | stat
Binding: RequestPriority (required): Identifies the level of importance to be assigned to actioning the request.

... doNotPerform ?!Σ0..1booleanTrue if service/procedure should not be performed
... code Σ1..1CodeableConceptWhat is being requested/ordered
Binding: ProcedureCodes(SNOMEDCT) (example): Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available here.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 3457005
..... display1..1stringRepresentation defined by the system
Fixed Value: 转诊
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... orderDetail ΣI0..*CodeableConceptAdditional order information
Binding: ServiceRequestOrderDetailsCodes (example): Codified order entry details which are based on order context.


... quantity[x] Σ0..1Service amount
.... quantityQuantityQuantity
.... quantityRatioRatio
.... quantityRangeRange
... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ1..1Reference(Encounter)指向转诊申请所属的诊疗活动资源,例如:随访活动
... occurrence[x] Σ0..1When service should occur
.... occurrenceDateTimedateTime
.... occurrencePeriodPeriod
.... occurrenceTimingTiming
... asNeeded[x] Σ0..1Preconditions for service
Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc.

.... asNeededBooleanboolean
.... asNeededCodeableConceptCodeableConcept
... authoredOn Σ1..1dateTime转诊请求时间
... requester Σ1..1Reference(卫生服务人员信息结构定义)指向转诊申请医师的引用
... performerType Σ0..1CodeableConceptPerformer role
Binding: ParticipantRoles (example): Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc.

... performer Σ2..*(Slice Definition)Requested performer
Slice: Unordered, Open by profile:.
.... performer:Department Σ1..1Reference(科室信息结构定义)转入科室
.... performer:Hospital Σ1..1Reference(医疗机构结构定义)转入机构
... locationCode Σ0..*CodeableConceptRequested location
Binding: ServiceDeliveryLocationRoleType (example): A location type where services are delivered.


... locationReference Σ0..*Reference(Location)Requested location
... reasonCode Σ0..1CodeableConcept转诊原因
Binding: ProcedureReasonCodes (example): Diagnosis or problem codes justifying the reason for requesting the service investigation.


... reasonReference Σ0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Explanation/Justification for service or service
... insurance 0..*Reference(Coverage | ClaimResponse)Associated insurance coverage
... supportingInfo 0..*Reference(Resource)Additional clinical information
... specimen Σ0..*Reference(Specimen)Procedure Samples
... bodySite Σ0..*CodeableConceptLocation on Body
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... note 0..*AnnotationComments
... patientInstruction Σ0..1stringPatient or consumer-oriented instructions
... relevantHistory 0..*Reference(Provenance)Request provenance

doco Documentation for this format

 

本定义的其它表示法: Schematron

Terminology Bindings

PathConformanceValueSet / Code
ServiceRequest.languagepreferredCommonLanguages
Max Binding: AllLanguages
ServiceRequest.statusrequiredRequestStatus
ServiceRequest.intentrequiredRequestIntent
ServiceRequest.categoryexampleServiceRequestCategoryCodes
ServiceRequest.priorityrequiredRequestPriority
ServiceRequest.codeexamplePattern: SNOMED CT code 3457005("转诊")
ServiceRequest.orderDetailexampleServiceRequestOrderDetailsCodes
ServiceRequest.asNeeded[x]exampleSNOMEDCTMedicationAsNeededReasonCodes
ServiceRequest.performerTypeexampleParticipantRoles
ServiceRequest.locationCodeexampleServiceDeliveryLocationRoleType
ServiceRequest.reasonCodeexampleProcedureReasonCodes
ServiceRequest.bodySiteexampleSNOMEDCTBodyStructures

Constraints

IdPathDetailsRequirements
dom-2ServiceRequestIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ServiceRequestIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4ServiceRequestIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5ServiceRequestIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ServiceRequestA resource should have narrative for robust management
: text.`div`.exists()
prr-1ServiceRequestorderDetail SHALL only be present if code is present
: orderDetail.empty() or code.exists()
ele-1ServiceRequest.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ServiceRequest.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ServiceRequest.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ServiceRequest.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ServiceRequest.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.replacesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.requisitionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.intentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.priorityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.doNotPerformAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.orderDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.quantity[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.occurrence[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.asNeeded[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.authoredOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.requesterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.performerTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.performer:DepartmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.performer:HospitalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.locationCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.locationReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.reasonCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.reasonReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.insuranceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.supportingInfoAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.specimenAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.patientInstructionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ServiceRequest.relevantHistoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())