{ "resourceType": "StructureDefinition", "id": "MedicationRequest", "url": "http://StructureDefinition.hl7fhir.cn/MedicationRequest", "name": "MedicationRequest", "title": "药品处方/医嘱", "status": "draft", "fhirVersion": "4.0.0", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern" }, { "identity": "script10.6", "uri": "http://ncpdp.org/SCRIPT10_6", "name": "Mapping to NCPDP SCRIPT 10.6" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" } ], "kind": "resource", "abstract": false, "type": "MedicationRequest", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "derivation": "constraint", "differential": { "element": [ { "id": "MedicationRequest", "path": "MedicationRequest", "short": "药品处方/医嘱", "definition": "给患者提供药物及用药说明的医嘱或处方。此资源可用于门诊、住院及照护方案等多种场景。在FHIR工作流框架中，它属于“请求”类资源。" }, { "id": "MedicationRequest.identifier", "path": "MedicationRequest.identifier", "type": [ { "code": "Identifier", "profile": [ "http://StructureDefinition.hl7fhir.cn/Identifier" ] } ] }, { "id": "MedicationRequest.status", "path": "MedicationRequest.status", "short": "活动状态", "definition": "用编码形式表示此医嘱当前状态。通常指活动状态或完成状态。\r\nactive | on-hold | cancelled | completed | entered-in-error | stopped | draft | unknown", "comment": "若此元素值的改变会引起整个药品处方意义发生改变。如：已取消、输入错误、已停止", "alias": [ "完成状态" ], "isModifierReason": "若此元素的值为“输入错误”时，此资源无效" }, { "id": "MedicationRequest.statusReason", "path": "MedicationRequest.statusReason", "short": "异常状态的原因", "definition": "造成当前“活动状态”（MedicationRequest.status）为“异常”的原因。", "comment": "仅当处于“异常”状态（如“暂停”或“取消”等）时才使用。\r\n不能用此元素来描述下达医嘱的原因（必须是在MedicationRequest.reasonCode中指定）。" }, { "id": "MedicationRequest.intent", "path": "MedicationRequest.intent", "short": "用药目的", "definition": "本次用药需求是属于医嘱、建议还是计划。\r\nproposal | plan | order | original-order | reflex-order | filler-order | instance-order | option\r\n建议 | 计划 | 医嘱 | 原始医嘱 | 生成医嘱 | 执行医嘱 | 用药记录| 子项", "comment": "根据用药请求所处的不同阶段，请求类型将受到限制。\r\n例如，用药需求和用药计划(plan)可以由患者、相关人员、医务人员甚至由设备创建。\r\n原始医嘱(original-order )只能由医务人员创建。\r\n实例医嘱(instance-order )是请求或医嘱的实例，可作为用药记录", "isModifierReason": "此元素会更改整个资源实际应用的时间和方式。 例如：当此元素值为“proposal”时，意为“执行医嘱的推荐时间”和“建议由谁来执行医嘱”； 当值为“order”时，意为“经授权的可执行医嘱的时间”与“授权谁可执行医嘱”。" }, { "id": "MedicationRequest.category", "path": "MedicationRequest.category", "short": "用药类别", "definition": "按用药地点对药品处方/医嘱的分类。例如，住院医嘱、门诊处方、出院带药等。", "comment": "分类编码可扩展", "binding": { "strength": "extensible", "description": "按用药地点对用药请求的分类编码：住院医嘱、门诊处方、出院带药等" } }, { "id": "MedicationRequest.priority", "path": "MedicationRequest.priority", "short": "优先级", "definition": "相对于其他医嘱，应以多快的速度响应并执行此医嘱。\r\nroutine | urgent | asap | stat\r\n常规|较急|尽快|立即" }, { "id": "MedicationRequest.doNotPerform", "path": "MedicationRequest.doNotPerform", "short": "停止执行", "definition": "如果此元素值为true，则表示医嘱下达者要求停止执行此药品医嘱。", "comment": "为了简化资源内容，建议仅当“停止医嘱”时才使用此元素。", "meaningWhenMissing": "如果未提供此元素，则意味着此医嘱需求被“执行”。", "isModifierReason": "此元素值的变理可能否定整个药品医嘱。即，要求停止执行此医嘱或处方。" }, { "id": "MedicationRequest.reported[x]", "path": "MedicationRequest.reported[x]", "short": "外部获取", "definition": "若此医嘱不是原始下达的而是从外部获取的，可以将元素值设为“true”，或者引用信息的来源。如，由患者口述的历史医嘱、转诊时从其它系统获取的医嘱信息。 指示是否将此记录捕获为次要的“已报告”记录，而不是真实记录的原始主源。它也可能指出报告的来源。", "type": [ { "code": "boolean" }, { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitonerRole", "http://StructureDefinition.hl7fhir.cn/RelatedPerson", "http://StructureDefinition.hl7fhir.cn/Organization" ] } ] }, { "id": "MedicationRequest.medication[x]", "path": "MedicationRequest.medication[x]", "short": "药物信息", "definition": "用于标识医嘱中的药物。可以使用药品编码，也可以引用一个药物资源（Medication）。", "comment": "如果只使用一个编码，则它必须是特定药品编码。如果需要更多信息（如药品的性状、批号或制剂等），建议使用药物资源。", "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Medication" ] } ] }, { "id": "MedicationRequest.subject", "path": "MedicationRequest.subject", "short": "用药对象", "definition": "此医嘱的用药对象，可以是一个患者或一个群体。", "comment": "药品处方/医嘱的用药患者不可或缺的。即使在某些情况下无法提供实际患者，也必须指定一个匿名对象。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/Group" ] } ] }, { "id": "MedicationRequest.encounter", "path": "MedicationRequest.encounter", "short": "相关就诊活动", "definition": "此医嘱/处方是在这个医疗就诊活动期间产生的，或与这个医疗就诊活动密切相关", "comment": "通常此医嘱/处方是在这个医疗就诊活动期间产生的，如果是在这个医疗活动正式开始之前或结束之后才产生的，那么它们之间一定关联紧密。\r\n 如果需要引用治疗/照护期资源（EpisodeOfCare），则请使用用扩展来处理。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Encounter" ] } ] }, { "id": "MedicationRequest.supportingInformation", "path": "MedicationRequest.supportingInformation", "short": "支撑信息", "definition": "支持此药品医嘱的附加信息（例如患者的身高体重）。" }, { "id": "MedicationRequest.authoredOn", "path": "MedicationRequest.authoredOn", "short": "下达时间", "definition": "下达医嘱（或对医嘱授权）的时间。" }, { "id": "MedicationRequest.requester", "path": "MedicationRequest.requester", "short": "用药申请人", "definition": "发起此用药申请并对请求生效后负责的个人、单位或设备。", "comment": "医护嘱或处方的申请人必须是医护人员。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitionerRole", "http://StructureDefinition.hl7fhir.cn/Organization", "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/RelatedPerson", "http://StructureDefinition.hl7fhir.cn/Device" ] } ] }, { "id": "MedicationRequest.performer", "path": "MedicationRequest.performer", "short": "给药者", "definition": "药物治疗的执行者，即给药者。", "comment": "当没有合适的人选时可以不填具体的执行人，可以通过MedicationRequest.performerType来说明对给药者的要求。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitionerRole", "http://StructureDefinition.hl7fhir.cn/Organization", "http://StructureDefinition.hl7fhir.cn/Patient", "http://StructureDefinition.hl7fhir.cn/RelatedPerson", "http://StructureDefinition.hl7fhir.cn/Device", "http://StructureDefinition.hl7fhir.cn/CareTeam" ] } ] }, { "id": "MedicationRequest.performerType", "path": "MedicationRequest.performerType", "short": "给药者要求", "definition": "对用药执行者的所属分类的要求。", "comment": "如果未填写给药者，则表示给药者必须属于此元素指定的分类。 如果填写了给药者的同时又填写了此无素，则意味着已填写的给药者并不是期望的最佳人选，并通过此元素来表示对给药者的要求。" }, { "id": "MedicationRequest.recorder", "path": "MedicationRequest.recorder", "short": "录入者", "definition": "录入（记录）医嘱的人，例如，某护士补录医生的口头医嘱或电话医嘱。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Practitioner", "http://StructureDefinition.hl7fhir.cn/PractitionerRole" ] } ] }, { "id": "MedicationRequest.reasonCode", "path": "MedicationRequest.reasonCode", "short": "用药理由编码", "definition": "用编码来表示在医嘱中使用或不使用相关药品的原因。", "comment": "由于JSON工作方式的限制，目前暂不支持元素以可选数据类型的方式重复出现。所以用MedicationRequest.reasonCode & MedicationRequest.reasonReference两个元素来表示相同的意义。下个FHIR版本中会将其合并。" }, { "id": "MedicationRequest.reasonReference", "path": "MedicationRequest.reasonReference", "short": "用药理由", "definition": "用病症与诊断资源（Condition）或观测资源（Observation）来说明用药原因。", "comment": "如果用药理由只有编码而没有具体的相关资源，可以使用MedicationRequest.reasonCode元素。由于JSON工作方式的限制，目前暂不支持元素以可选数据类型的方式重复出现。所以用MedicationRequest.reasonCode & MedicationRequest.reasonReference两个元素来表示相同的意义。下个FHIR版本中会将其合并。", "type": [ { "code": "Reference", "targetProfile": [ "http://StructureDefinition.hl7fhir.cn/Condition", "http://StructureDefinition.hl7fhir.cn/Observation" ] } ] }, { "id": "MedicationRequest.instantiatesCanonical", "path": "MedicationRequest.instantiatesCanonical", "short": "遵循的定义", "definition": "此药品医嘱需要完全遵守或部分遵守的指南、规章等。", "comment": "由于JSON工作方式的限制，目前暂不支持元素以可选数据类型的方式重复出现。所以用MedicationRequest.instantiatesCanonical 和 MedicationRequest.instantiatesUri两个元素来表示相同的意义。下个FHIR版本中会将其合并。" }, { "id": "MedicationRequest.instantiatesUri", "path": "MedicationRequest.instantiatesUri", "short": "遵循的外部定义", "definition": "此药品医嘱需要完全遵守或部分遵守的外部指南、规章等。", "comment": "由于JSON工作方式的限制，目前暂不支持元素以可选数据类型的方式重复出现。所以用MedicationRequest.instantiatesCanonical 和 MedicationRequest.instantiatesUri两个元素来表示相同的意义。下个FHIR版本中会将其合并。" }, { "id": "MedicationRequest.basedOn", "path": "MedicationRequest.basedOn", "short": "为完成什么计划或请求", "definition": "此药品请求资源是基于此元素中的计划类资源或请求类资源来的，即此元素中的资源的实现是全部或部分由此药品请求资源来完成的。" }, { "id": "MedicationRequest.groupIdentifier", "path": "MedicationRequest.groupIdentifier", "short": "组合ID", "definition": "用于标识医嘱/处方/请求的ID，它是由一组几乎在同一时间下达的医嘱共同使用的组别ID。", "requirements": "医嘱/处方/请求可以通过两种方式关联，一是使用\"MedicationRequest.basedOn\"元素直接引用关联，二是使用此元素来建立一个共用的分组。 组内的单个医嘱/处方/请求在其创建后通常是单独维护，对其状态的变更也是分别进行的。", "alias": [ "医嘱ID" ], "type": [ { "code": "Identifier", "profile": [ "http://StructureDefinition.hl7fhir.cn/Identifier" ] } ] }, { "id": "MedicationRequest.courseOfTherapyType", "path": "MedicationRequest.courseOfTherapyType", "short": "用药模式", "definition": "患者用药的模式，如：长期、临时。", "comment": "此元素不能用于表示药品规定（说明）。" }, { "id": "MedicationRequest.insurance", "path": "MedicationRequest.insurance", "short": "相关保险信息", "definition": "此用药医嘱/处方/请求相关的医保或商保信息，包括理赔范围、预审核信息。" }, { "id": "MedicationRequest.insurance.identifier", "path": "MedicationRequest.insurance.identifier", "type": [ { "code": "Identifier", "profile": [ "http://StructureDefinition.hl7fhir.cn/Identifier" ] } ] }, { "id": "MedicationRequest.note", "path": "MedicationRequest.note", "type": [ { "code": "Annotation", "profile": [ "http://StructureDefinition.hl7fhir.cn/Annotation" ] } ] }, { "id": "MedicationRequest.dosageInstruction", "path": "MedicationRequest.dosageInstruction", "short": "用法与用量", "definition": "患者如何使用药物。", "type": [ { "code": "Dosage", "profile": [ "http://StructureDefinition.hl7fhir.cn/Dosage" ] } ] } ] } }