{
  "resourceType": "StructureDefinition",
  "id": "medical-record-documentation",
  "meta": {
    "lastUpdated": "2020-12-07T02:06:47.065+00:00"
  },
  "url": "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/medical-record-documentation",
  "name": "MedicalRecordDocumentation",
  "title": "病历文档引用",
  "status": "draft",
  "description": "引用第三方的病历文书，并且把病历文书作为附件形式上传。",
  "fhirVersion": "4.0.1",
  "mapping": [
    {
      "identity": "workflow",
      "uri": "http://hl7.org/fhir/workflow",
      "name": "Workflow Pattern"
    },
    {
      "identity": "fhircomposition",
      "uri": "http://hl7.org/fhir/composition",
      "name": "FHIR Composition"
    },
    {
      "identity": "rim",
      "uri": "http://hl7.org/v3",
      "name": "RIM Mapping"
    },
    {
      "identity": "cda",
      "uri": "http://hl7.org/v3/cda",
      "name": "CDA (R2)"
    },
    {
      "identity": "w5",
      "uri": "http://hl7.org/fhir/fivews",
      "name": "FiveWs Pattern Mapping"
    },
    {
      "identity": "v2",
      "uri": "http://hl7.org/v2",
      "name": "HL7 v2 Mapping"
    },
    {
      "identity": "xds",
      "uri": "http://ihe.net/xds",
      "name": "XDS metadata equivalent"
    }
  ],
  "kind": "resource",
  "abstract": false,
  "type": "DocumentReference",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DocumentReference",
  "derivation": "constraint",
  "differential": {
    "element": [
      {
        "id": "DocumentReference",
        "path": "DocumentReference",
        "short": "病历文档引用",
        "definition": "引用第三方的病历文书，并且把病历文书作为附件形式上传。引用任何种类的文件。提供关于文档的元数据，以便发现和管理文档。文档的范围是任何具有mime类型的串行化对象，因此包括正式的以患者为中心的文档(CDA)、cliical notes、扫描的纸张和非患者特定的文档(如策略文本)。"
      },
      {
        "id": "DocumentReference.masterIdentifier",
        "path": "DocumentReference.masterIdentifier",
        "short": "文档编号",
        "type": [
          {
            "code": "Identifier",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Identifier"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.identifier",
        "path": "DocumentReference.identifier",
        "short": "其他标识符",
        "definition": "描述本病历文档的其他业务标识符",
        "type": [
          {
            "code": "Identifier",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Identifier"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.status",
        "path": "DocumentReference.status",
        "short": "该文档引用的状态",
        "definition": "该文档引用的状态"
      },
      {
        "id": "DocumentReference.status.extension",
        "path": "DocumentReference.status.extension",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "url"
            }
          ],
          "rules": "open"
        }
      },
      {
        "id": "DocumentReference.status.extension:status",
        "path": "DocumentReference.status.extension",
        "sliceName": "status",
        "short": "文档引用的状态",
        "definition": "描述文档引用的基本状态  当前 被取代 输入错误的",
        "max": "1",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/resource-status"
            ]
          }
        ],
        "binding": {
          "strength": "required",
          "description": "文档引用的状态",
          "valueSet": "http://fhir.scwjxx.cn/Sichuan/ValueSet/document-reference-status-vs"
        }
      },
      {
        "id": "DocumentReference.docStatus",
        "path": "DocumentReference.docStatus",
        "short": "文档状态",
        "definition": "文档状态"
      },
      {
        "id": "DocumentReference.docStatus.extension",
        "path": "DocumentReference.docStatus.extension",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "url"
            }
          ],
          "rules": "open"
        }
      },
      {
        "id": "DocumentReference.docStatus.extension:docStatus",
        "path": "DocumentReference.docStatus.extension",
        "sliceName": "docStatus",
        "short": "文档状态",
        "definition": "文档状态  初步| 最后 修改 输入错误的",
        "max": "1",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/resource-status"
            ]
          }
        ],
        "binding": {
          "strength": "required",
          "valueSet": "http://fhir.scwjxx.cn/Sichuan/ValueSet/composition-status-vs"
        }
      },
      {
        "id": "DocumentReference.type",
        "path": "DocumentReference.type",
        "short": "文档分类",
        "definition": "描述病历文档在国家标准下的一个分类",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ],
        "binding": {
          "strength": "preferred",
          "description": "文档分类",
          "valueSet": "http://fhir.scwjxx.cn/Sichuan/ValueSet/document-type-vs"
        }
      },
      {
        "id": "DocumentReference.category",
        "path": "DocumentReference.category",
        "short": "文档类别",
        "definition": "描述在文档分类下的确定文档类型。",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ],
        "binding": {
          "strength": "example",
          "valueSet": "http://fhir.scwjxx.cn/Sichuan/ValueSet/document-category-vs"
        }
      },
      {
        "id": "DocumentReference.subject",
        "path": "DocumentReference.subject",
        "short": "该文档描述的主体",
        "definition": "该文档描述的主体",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.date",
        "path": "DocumentReference.date",
        "short": "文档引用创建日期",
        "definition": "文档引用创建日期"
      },
      {
        "id": "DocumentReference.author",
        "path": "DocumentReference.author",
        "short": "文档作者",
        "definition": "确定谁负责将信息添加到文档中。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.authenticator",
        "path": "DocumentReference.authenticator",
        "short": "文档审核者",
        "definition": "哪个人或组织验证此文档的有效性。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.custodian",
        "path": "DocumentReference.custodian",
        "short": "管理机构",
        "definition": "标识负责对文档进行持续维护和访问的组织或组。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.relatesTo",
        "path": "DocumentReference.relatesTo",
        "max": "0"
      },
      {
        "id": "DocumentReference.description",
        "path": "DocumentReference.description",
        "short": "文档描述",
        "definition": "文档描述"
      },
      {
        "id": "DocumentReference.securityLabel",
        "path": "DocumentReference.securityLabel",
        "short": "安全级别",
        "definition": "描述文档的安全级别",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ],
        "binding": {
          "strength": "extensible",
          "description": "密级",
          "valueSet": "http://fhir.scwjxx.cn/Sichuan/ValueSet/security-labels-vs"
        }
      },
      {
        "id": "DocumentReference.content.attachment",
        "path": "DocumentReference.content.attachment",
        "short": "文档实体",
        "type": [
          {
            "code": "Attachment",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Attachment"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.content.format",
        "path": "DocumentReference.content.format",
        "max": "0",
        "type": [
          {
            "code": "Coding",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Coding"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context",
        "path": "DocumentReference.context",
        "short": "临床背景",
        "definition": "文件的临床背景"
      },
      {
        "id": "DocumentReference.context.encounter",
        "path": "DocumentReference.context.encounter",
        "short": "医疗事件",
        "definition": "描述文档内容所关联的临床遭遇或护理类型。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.event",
        "path": "DocumentReference.context.event",
        "short": "临床行为",
        "definition": "已记录的主要临床行为",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.period",
        "path": "DocumentReference.context.period",
        "short": "时间段",
        "definition": "文档所描述的服务被提供的时间段。",
        "type": [
          {
            "code": "Period",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Period"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.facilityType",
        "path": "DocumentReference.context.facilityType",
        "short": "机构类型代码",
        "definition": "这是代表发生临床遭遇，服务，交互作用或治疗的组织机构类型的代码。",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.practiceSetting",
        "path": "DocumentReference.context.practiceSetting",
        "short": "主题领域",
        "definition": "此属性可以传达有关创建内容的实践环境的细节，通常反映出临床专业知识。\r\n该要素应基于专业实践课的粗略分类系统。建议将分类系统用于练习设置，例如LOINC中的“主题领域”所描述的系统。",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/CodeableConcept"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.sourcePatientInfo",
        "path": "DocumentReference.context.sourcePatientInfo",
        "short": "患者信息",
        "definition": "文档发布时所知道的患者信息。可能是特定版本的引用，也可能是包含的引用。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      },
      {
        "id": "DocumentReference.context.related",
        "path": "DocumentReference.context.related",
        "short": "相关信息",
        "definition": "与DocumentReference关联的相关标识符或资源。",
        "type": [
          {
            "code": "Reference",
            "profile": [
              "http://fhir.scwjxx.cn/Sichuan/StructureDefinition/Reference"
            ]
          }
        ]
      }
    ]
  }
}