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: 外伤史结构定义

Defining URL:http://hl7.org.cn/fhir/sd/ehr/StructureDefinition/profile-wound-history
Version:0.8.0.2022705
Name:WoundHistory
Title:外伤史结构定义
Status:Active as of 2022-07-05T13:46:42+08:00
Definition:

外伤史结构定义。

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

外伤史结构定义的正式唯一标识为: 

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

定义内容的视图

外伤史结构定义是在FHIR标准的Condition基础上进行更加详细的规则约束，下表展示了外伤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。

这种结构源自 Condition

Summary

Mandatory: 3 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

这种结构源自 Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... category 1..1CodeableConceptproblem-list-item | encounter-diagnosis
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://terminology.hl7.org/CodeSystem/condition-category
..... 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
... code 1..1CodeableConcept记录居民的既往外伤情况。
.... text 1..1string在此位置记录居民的既往外伤情况
... subject 1..1Reference(患者信息结构定义)指向患者的引用

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*ConditionDetailed 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 ?!ΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
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..1CodeableConcept记录居民的既往外伤情况。
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 Σ0..*CodingCode defined by a terminology system
.... text Σ1..1string在此位置记录居民的既往外伤情况
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] SΣ0..1外伤时间。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
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... 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)Who recorded the condition
... 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..*AnnotationAdditional information about the Condition

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*ConditionDetailed information about conditions, problems or diagnoses
... onset[x] Σ0..1外伤时间。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
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring

doco Documentation for this format

这种结构源自 Condition

Summary

Mandatory: 3 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

差异视图

这种结构源自 Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... category 1..1CodeableConceptproblem-list-item | encounter-diagnosis
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://terminology.hl7.org/CodeSystem/condition-category
..... 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
... code 1..1CodeableConcept记录居民的既往外伤情况。
.... text 1..1string在此位置记录居民的既往外伤情况
... subject 1..1Reference(患者信息结构定义)指向患者的引用

doco Documentation for this format

快照视图

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*ConditionDetailed 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 ?!ΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
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..1CodeableConcept记录居民的既往外伤情况。
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 Σ0..*CodingCode defined by a terminology system
.... text Σ1..1string在此位置记录居民的既往外伤情况
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject Σ1..1Reference(患者信息结构定义)指向患者的引用
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] SΣ0..1外伤时间。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
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... 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)Who recorded the condition
... 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..*AnnotationAdditional information about the Condition

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.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.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.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())