基于FHIR标准的健康档案共享文档实施指南-手术史结构定义

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: 手术史结构定义

Defining URL:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-surgery-history

Version:

0.8.0.2022705

Name:

SurgeryHistory

Title:

手术史结构定义

Status:

Active as of 2022-07-05T13:46:42+08:00

Definition:

手术史结构定义。

Publisher:

CHIMA&HL7中国委员会

Source Resource:

XML / JSON / Turtle

手术史结构定义的正式唯一标识为:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-surgery-history

定义内容的视图

手术史结构定义是在FHIR标准的Procedure基础上进行更加详细的规则约束，下表展示了手术史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。

文本摘要
差异表
快照表
快照表(Must Support)
All

这种结构源自 Procedure

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-core-patient

这种结构源自 Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
status		1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Required Pattern: completed
code		1..1	CodeableConcept	记录居民的手术史
text		1..1	string	在此位置记录居民的手术描述
subject		1..1	Reference(患者信息结构定义)	指向患者的引用
performed[x]	S	0..1	dateTime, Period, string, Age, Range	手术时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	Part of referenced event
status	?!Σ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	Σ	1..1	CodeableConcept	记录居民的手术史 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	1..1	string	在此位置记录居民的手术描述
subject	Σ	1..1	Reference(患者信息结构定义)	指向患者的引用
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	0..1		手术时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device \| Medication \| Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
performed[x]	Σ	0..1		手术时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
Documentation for this format

这种结构源自 Procedure

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-core-patient

差异视图

这种结构源自 Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
status		1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Required Pattern: completed
code		1..1	CodeableConcept	记录居民的手术史
text		1..1	string	在此位置记录居民的手术描述
subject		1..1	Reference(患者信息结构定义)	指向患者的引用
performed[x]	S	0..1	dateTime, Period, string, Age, Range	手术时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
Documentation for this format

快照视图

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	Part of referenced event
status	?!Σ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	Σ	1..1	CodeableConcept	记录居民的手术史 Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	1..1	string	在此位置记录居民的手术描述
subject	Σ	1..1	Reference(患者信息结构定义)	指向患者的引用
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	0..1		手术时间。可以提供精确时间，也可以提供时间区间，或者发生时的年龄
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device \| Medication \| Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

本定义的其它表示法: Schematron

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Max Binding: AllLanguages
Procedure.status	required	Pattern: completed
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	example	ProcedureCodes(SNOMEDCT)
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.bodySite	example	SNOMEDCTBodyStructures
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes
Procedure.usedCode	example	FHIRDeviceTypes

Constraints

Id	Path	Details	Requirements
dom-2	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	Procedure	If 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-4	Procedure	If 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-5	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	Procedure.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.instantiatesCanonical	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.instantiatesUri	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.statusReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.code.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.code.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.code.coding	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.code.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.performed[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.recorder	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.asserter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.performer	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.performer.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.performer.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.performer.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.performer.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.performer.function	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.performer.actor	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.performer.onBehalfOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.location	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.reasonCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.reasonReference	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.outcome	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.report	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.complication	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.complicationDetail	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.followUp	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.focalDevice	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.focalDevice.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.focalDevice.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.focalDevice.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Procedure.focalDevice.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Procedure.focalDevice.action	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.focalDevice.manipulated	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.usedReference	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Procedure.usedCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())