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: 冠心病症结构定义

Defining URL:http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-symptoms-chd
Version:0.8.0.2022705
Name:CHDSymptoms
Title:冠心病症结构定义
Status:Active as of 2022-07-05T13:46:42+08:00
Definition:

冠心病症状资源本地化定义。

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

冠心病症结构定义的正式唯一标识为: 

http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-symptoms-chd

简介

冠心病症状信息使用Condition资源进行表示。该资源的本地化结构定义声明了对适用于医疗健康信息平台中症状信息的最低要求。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

冠心病症状编码记录在code.coding元素中，症状名称则记录在code.text元素中。需要注意的是，code.coding.display元素也会记录症状编码所对应的显示名称，如果与记录在code.text元素中的一致，则code.text元素可以忽略

定义内容的视图

冠心病症结构定义是在FHIR标准的Symptoms基础上进行更加详细的规则约束，下表展示了冠心病症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 Symptoms

Summary

Mandatory: 3 elements

Slices

This structure defines the following Slices:

  • The element Condition.code.coding is sliced based on the value of value:system

这种结构源自 Symptoms

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*SymptomsDetailed information about conditions, problems or diagnoses
... code 1..1CodeableConceptIdentification of the condition, problem or diagnosis
.... coding 2..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:Local 1..1Coding编码来自国家公卫基本服务规范
Binding: 冠心病症状代码表 (required)
..... coding:ICD10R 1..1Coding编码来自ICD-10-R
Binding: ICD-10症状代码表 (required)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SymptomsDetailed information about conditions, problems or diagnoses
... 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
... 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..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣI1..1CodeableConcept记录症状的临床状态。例如：活跃、不活跃、已解决等
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!ΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category 1..1CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



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://terminology.hl7.org/CodeSystem/condition-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: 问题列表
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ2..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:Local Σ1..1Coding编码来自国家公卫基本服务规范
Binding: 冠心病症状代码表 (required)
..... coding:ICD10R Σ1..1Coding编码来自ICD-10-R
Binding: ICD-10症状代码表 (required)
.... text Σ0..1stringPlain text representation of the concept
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject Σ1..1Reference(Patient)指向患者的引用
... encounter Σ1..1Reference(Encounter)指向诊疗活动资源，例如：随访、门诊、住院等
... onset[x] Σ0..1(Slice Definition)Estimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime Σ0..1dateTime症状开始时间，可以是估计时间
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)症状记录医师
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SymptomsDetailed information about conditions, problems or diagnoses

doco Documentation for this format

这种结构源自 Symptoms

Summary

Mandatory: 3 elements

Slices

This structure defines the following Slices:

  • The element Condition.code.coding is sliced based on the value of value:system

差异视图

这种结构源自 Symptoms

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*SymptomsDetailed information about conditions, problems or diagnoses
... code 1..1CodeableConceptIdentification of the condition, problem or diagnosis
.... coding 2..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:Local 1..1Coding编码来自国家公卫基本服务规范
Binding: 冠心病症状代码表 (required)
..... coding:ICD10R 1..1Coding编码来自ICD-10-R
Binding: ICD-10症状代码表 (required)

doco Documentation for this format

快照视图

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SymptomsDetailed information about conditions, problems or diagnoses
... 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
... 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..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣI1..1CodeableConcept记录症状的临床状态。例如：活跃、不活跃、已解决等
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!ΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category 1..1CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



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://terminology.hl7.org/CodeSystem/condition-category
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: 问题列表
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ2..*(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:Local Σ1..1Coding编码来自国家公卫基本服务规范
Binding: 冠心病症状代码表 (required)
..... coding:ICD10R Σ1..1Coding编码来自ICD-10-R
Binding: ICD-10症状代码表 (required)
.... text Σ0..1stringPlain text representation of the concept
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject Σ1..1Reference(Patient)指向患者的引用
... encounter Σ1..1Reference(Encounter)指向诊疗活动资源，例如：随访、门诊、住院等
... onset[x] Σ0..1(Slice Definition)Estimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime Σ0..1dateTime症状开始时间，可以是估计时间
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)症状记录医师
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*Annotation关于该症状的附加信息

doco Documentation for this format

 

本定义的其它表示法: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Condition.languagepreferredCommonLanguages
Max Binding: AllLanguages
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensiblePattern: problem-list-item("问题列表")
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeexampleCondition/Problem/DiagnosisCodes
Condition.code.coding:LocalrequiredSymptomCHDCodes
Condition.code.coding:ICD10RrequiredICD10R
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

Constraints

IdPathDetailsRequirements
con-3ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4ConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5ConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ConditionIf 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-4ConditionIf 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-5ConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1Condition.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.clinicalStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.verificationStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.severityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.code.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.code.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding:LocalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding:ICD10RAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.onset[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.onset[x]:onsetDateTimeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.abatement[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recordedDateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recorderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.asserterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.summaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.assessmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())