HL7中国FHIR Connectathon测试实施指南
V20230304 - release

HL7中国FHIR Connectathon测试实施指南 - Local Development build (vV20230304). See the Directory of published versions

: DischargeSummaryDocumentExample01 - JSON Representation

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{
  "resourceType" : "Bundle",
  "id" : "DischargeSummaryDocumentExample01",
  "meta" : {
    "profile" : [
      "http://hl7.org.cn/fhir/StructureDefinition/profile-ClinicalDocumentBundle"
    ]
  },
  "type" : "document",
  "entry" : [
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-312",
      "resource" : {
        "resourceType" : "Composition",
        "id" : "DischargeSummaryCompositionExampleInline01",
        "meta" : {
          "profile" : [
            "http://hl7.org.cn/fhir/StructureDefinition/profile-discharge-summary-document"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: N123455</p><p><b>status</b>: final</p><p><b>type</b>: <span title=\"Codes: {http://hl7.org.cn/fhir/CodeSystem/emr-document-type C0053}\">出院小结</span></p><p><b>category</b>: <span title=\"Codes: {http://hl7.org.cn/fhir/CodeSystem/document-category EMR}\">电子病历共享文档</span></p><p><b>encounter</b>: <a href=\"#Encounter_EncounterExampleInline01\">See above (Encounter/EncounterExampleInline01)</a></p><p><b>date</b>: 2002年8月24日 上午5:45:50</p><p><b>author</b>: <a href=\"#Practitioner_PractitionerExample01\">赵勇. Generated Summary: 赵勇; gender: male</a></p><p><b>title</b>: 出院小结</p><p><b>custodian</b>: <a href=\"#Organization_OrganizationExample03\">北大人民医院. Generated Summary: name: 北大人民医院</a></p></div>"
        },
        "identifier" : {
          "system" : "urn:oid:1.2.10093.1.23.24.3454354",
          "value" : "N123455"
        },
        "status" : "final",
        "type" : {
          "coding" : [
            {
              "system" : "http://hl7.org.cn/fhir/CodeSystem/emr-document-type",
              "code" : "C0053",
              "display" : "出院小结"
            }
          ]
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://hl7.org.cn/fhir/CodeSystem/document-category",
                "code" : "EMR",
                "display" : "电子病历共享文档"
              }
            ]
          }
        ],
        "subject" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
          "display" : "张三"
        },
        "encounter" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-313"
        },
        "date" : "2002-08-23T16:45:50.597-05:00",
        "author" : [
          {
            "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-315",
            "display" : "赵勇"
          }
        ],
        "title" : "出院小结",
        "custodian" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-316",
          "display" : "北大人民医院"
        },
        "section" : [
          {
            "title" : "入院原因",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "29299-5",
                  "display" : "Reason for visit"
                }
              ]
            },
            "entry" : [
              {
                "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-317",
                "display" : "发热"
              }
            ]
          },
          {
            "title" : "出院诊断",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "11535-2",
                  "display" : "Hospital discharge diagnosis"
                }
              ]
            },
            "entry" : [
              {
                "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-318",
                "display" : "新冠肺炎"
              }
            ]
          },
          {
            "title" : "出院用药",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "10183-2",
                  "display" : "Hospital discharge medications"
                }
              ]
            },
            "entry" : [
              {
                "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-319",
                "display" : "洛匹那韦"
              }
            ]
          },
          {
            "title" : "过敏和不良反应",
            "code" : {
              "coding" : [
                {
                  "system" : "http://loinc.org",
                  "code" : "48765-2",
                  "display" : "Allergies and adverse reactions"
                }
              ]
            },
            "entry" : [
              {
                "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-320",
                "display" : "麻疹"
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-313",
      "resource" : {
        "resourceType" : "Encounter",
        "id" : "EncounterExampleInline01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>status</b>: finished</p><p><b>class</b>: <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ActCode IMP}\">住院诊疗</span></p><p><b>type</b>: <span title=\"Codes: \">新冠肺炎入院</span></p><p><b>subject</b>: <a href=\"#Patient_PatientExample01\">张三. Generated Summary: active; 张三; Phone: 010-1234567; gender: female; birthDate: 1955-10-25</a></p><p><b>period</b>: 2021年5月7日 下午12:30:02 --&gt; 2002年8月20日 下午4:45:50</p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Condition</b></td><td><b>Use</b></td></tr><tr><td>*</td><td><a href=\"#Condition_DischargeDiagnosisExampleInline01\">新冠肺炎. Generated Summary: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}\">诊断</span>; <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10 J12.82}\">新冠肺炎</span></a></td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/diagnosis-role DD}\">出院诊断</span></td></tr></table><p><b>serviceProvider</b>: <a href=\"#Organization_OrganizationExample03\">北大人民医院. Generated Summary: name: 北大人民医院</a></p></div>"
        },
        "status" : "finished",
        "class" : {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
          "code" : "IMP",
          "display" : "住院诊疗"
        },
        "type" : [
          {
            "text" : "新冠肺炎入院"
          }
        ],
        "subject" : {
          "reference" : "Patient/PatientExample01",
          "display" : "张三"
        },
        "period" : {
          "start" : "2021-05-07T12:30:02+08:00",
          "end" : "2002-08-20T16:45:50+08:00"
        },
        "diagnosis" : [
          {
            "condition" : {
              "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-318",
              "display" : "新冠肺炎"
            },
            "use" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/diagnosis-role",
                  "code" : "DD",
                  "display" : "出院诊断"
                }
              ]
            }
          }
        ],
        "serviceProvider" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-316",
          "display" : "北大人民医院"
        }
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "PatientExample01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>active</b>: true</p><p><b>name</b>: 张三</p><p><b>telecom</b>: ph: 010-1234567(WORK)</p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1955-10-25</p><p><b>address</b>: 北京市东城区某某小区10号楼9单999室 (HOME)</p></div>"
        },
        "active" : true,
        "name" : [
          {
            "text" : "张三",
            "family" : "张",
            "given" : [
              "三"
            ]
          }
        ],
        "telecom" : [
          {
            "system" : "phone",
            "value" : "010-1234567",
            "use" : "work"
          }
        ],
        "gender" : "female",
        "birthDate" : "1955-10-25",
        "address" : [
          {
            "use" : "home",
            "line" : [
              "北京市东城区某某小区10号楼9单999室"
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-315",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "PractitionerExample01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>name</b>: 赵勇</p><p><b>gender</b>: male</p></div>"
        },
        "name" : [
          {
            "text" : "赵勇",
            "family" : "赵",
            "given" : [
              "勇"
            ]
          }
        ],
        "gender" : "male"
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-316",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "OrganizationExample03",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>name</b>: 北大人民医院</p></div>"
        },
        "name" : "北大人民医院"
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-317",
      "resource" : {
        "resourceType" : "Observation",
        "id" : "SymptomExampleInline01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10 R50}\">发热</span></p><p><b>subject</b>: <a href=\"#Patient_PatientExample01\">张三. Generated Summary: active; 张三; Phone: 010-1234567; gender: female; birthDate: 1955-10-25</a></p><p><b>encounter</b>: <a href=\"#Encounter_EncounterExampleInline01\">See above (Encounter/EncounterExampleInline01)</a></p></div>"
        },
        "status" : "final",
        "code" : {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/sid/icd-10",
              "code" : "R50",
              "display" : "发热"
            }
          ]
        },
        "subject" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
          "display" : "张三"
        },
        "encounter" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-313"
        }
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-318",
      "resource" : {
        "resourceType" : "Condition",
        "id" : "DischargeDiagnosisExampleInline01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}\">诊断</span></p><p><b>code</b>: <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10 J12.82}\">新冠肺炎</span></p><p><b>subject</b>: <a href=\"#Patient_PatientExample01\">张三. Generated Summary: active; 张三; Phone: 010-1234567; gender: female; birthDate: 1955-10-25</a></p><p><b>encounter</b>: <a href=\"#Encounter_EncounterExampleInline01\">See above (Encounter/EncounterExampleInline01)</a></p></div>"
        },
        "category" : [
          {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
                "code" : "encounter-diagnosis",
                "display" : "诊断"
              }
            ]
          }
        ],
        "code" : {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/sid/icd-10",
              "code" : "J12.82",
              "display" : "Pneumonia due to COVID-19"
            }
          ],
          "text" : "新冠肺炎"
        },
        "subject" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
          "display" : "张三"
        },
        "encounter" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-313"
        }
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-319",
      "resource" : {
        "resourceType" : "MedicationRequest",
        "id" : "MedicationRequestExampleInline01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>intent</b>: order</p><p><b>medication</b>: <span title=\"Codes: {http://snomed.info/sct XXXXXX}\">洛匹那韦</span></p><p><b>subject</b>: <a href=\"#Patient_PatientExample01\">张三. Generated Summary: active; 张三; Phone: 010-1234567; gender: female; birthDate: 1955-10-25</a></p><p><b>encounter</b>: <a href=\"#Encounter_EncounterExampleInline01\">See above (Encounter/EncounterExampleInline01)</a></p><p><b>authoredOn</b>: 2002年8月20日 下午4:45:50</p><p><b>requester</b>: <a href=\"#Practitioner_PractitionerExample01\">赵勇. Generated Summary: 赵勇; gender: male</a></p><p><b>reasonReference</b>: <a href=\"#Condition_DischargeDiagnosisExampleInline01\">新冠肺炎. Generated Summary: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}\">诊断</span>; <span title=\"Codes: {http://hl7.org/fhir/sid/icd-10 J12.82}\">新冠肺炎</span></a></p><p><b>groupIdentifier</b>: id: pres123456</p><p><b>note</b>: 药品用法,备注说明等</p><h3>DosageInstructions</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table><h3>DispenseRequests</h3><table class=\"grid\"><tr><td>-</td><td><b>Quantity</b></td></tr><tr><td>*</td><td>20 盒</td></tr></table></div>"
        },
        "status" : "active",
        "intent" : "order",
        "medicationCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "XXXXXX",
              "display" : "洛匹那韦"
            }
          ],
          "text" : "洛匹那韦"
        },
        "subject" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
          "display" : "张三"
        },
        "encounter" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-313"
        },
        "authoredOn" : "2002-08-20T16:45:50+08:00",
        "requester" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-315",
          "display" : "赵勇"
        },
        "reasonReference" : [
          {
            "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-318",
            "display" : "新冠肺炎"
          }
        ],
        "groupIdentifier" : {
          "system" : "http://xxxxxx.com.cn/org-xxxx/prescription",
          "value" : "pres123456"
        },
        "note" : [
          {
            "text" : "药品用法,备注说明等"
          }
        ],
        "dosageInstruction" : [
          {
            "timing" : {
              "repeat" : {
                "boundsPeriod" : {
                  "start" : "2002-08-20T16:45:50+08:00",
                  "end" : "2002-09-20T16:45:50+08:00"
                }
              },
              "code" : {
                "coding" : [
                  {
                    "system" : "http://terminology.hl7.org/CodeSystem/v3-GTSAbbreviation",
                    "code" : "BID",
                    "display" : "每日两次"
                  }
                ]
              }
            },
            "route" : {
              "coding" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "26643006",
                  "display" : "口服"
                }
              ]
            },
            "doseAndRate" : [
              {
                "doseQuantity" : {
                  "value" : 2,
                  "system" : "http://unitsofmeasure.org",
                  "code" : "片"
                }
              }
            ]
          }
        ],
        "dispenseRequest" : {
          "quantity" : {
            "value" : 20,
            "system" : "http://unitsofmeasure.org",
            "code" : "盒"
          }
        }
      }
    },
    {
      "fullUrl" : "urn:uuid:112312312-12-31-23-12-31-23-12-320",
      "resource" : {
        "resourceType" : "AllergyIntolerance",
        "id" : "AllergiesExampleInline01",
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>clinicalStatus</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical resolved}\">已解决</span></p><p><b>verificationStatus</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/allergyintolerance-verification confirmed}\">已确认</span></p><p><b>type</b>: allergy</p><p><b>criticality</b>: high</p><p><b>code</b>: <span title=\"Codes: \">青霉素</span></p><p><b>patient</b>: <a href=\"#Patient_PatientExample01\">张三. Generated Summary: active; 张三; Phone: 010-1234567; gender: female; birthDate: 1955-10-25</a></p><p><b>encounter</b>: <a href=\"#Encounter_EncounterExampleInline01\">See above (Encounter/EncounterExampleInline01)</a></p><p><b>recordedDate</b>: 2021-08-20</p><h3>Reactions</h3><table class=\"grid\"><tr><td>-</td><td><b>Manifestation</b></td></tr><tr><td>*</td><td><span title=\"Codes: {http://example.org/system xxx}\">麻疹</span></td></tr></table></div>"
        },
        "clinicalStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
              "code" : "resolved",
              "display" : "已解决"
            }
          ]
        },
        "verificationStatus" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
              "code" : "confirmed",
              "display" : "已确认"
            }
          ]
        },
        "type" : "allergy",
        "criticality" : "high",
        "code" : {
          "text" : "青霉素"
        },
        "patient" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-314",
          "display" : "张三"
        },
        "encounter" : {
          "reference" : "urn:uuid:112312312-12-31-23-12-31-23-12-313"
        },
        "recordedDate" : "2021-08-20",
        "reaction" : [
          {
            "manifestation" : [
              {
                "coding" : [
                  {
                    "system" : "http://example.org/system",
                    "code" : "xxx",
                    "display" : "Hives"
                  }
                ],
                "text" : "麻疹"
              }
            ]
          }
        ]
      }
    }
  ]
}