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 - XML Representation

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