工作组: Patient Care 标准状态: Informative

9.0 临床组件

9.0.1 简介

临床组件（Clinical Module）集中关注的是那些表示患者之核心临床信息的FHIR资源。 这些资源之中所包含的是医疗服务人员在临床医疗/照护服务过程中所经常记载、创建或获取的信息。 诊断学检查（diagnostic studies）过程中所产生的资源属于诊断组件（Diagnostics Module）， 而与药物的医嘱/处方开立和施用过程相关的资源则属于药物组件（Medications Module）。

关于FHIR APIs和资源的入门介绍，请参阅 基础组件（Foundation Module） 概述章节里的写给开发人员, 写给医护人员 , 和 写给架构师 开发人员入门 或 临床人员入门。

9.0.2 索引

本临床组件涵盖了下列资源：

从FHIR资源之中主元素和子元素的数量，以及所引用资源的数量上来说，此组件和其他FHIR组件之中的FHIR资源分别会有着不同的复杂程度（低、中、高）。 为了更好地了解和认识资源之间的关系，我们建议在处理 照护计划 资源之类高度复杂的资源之前，先从那些复杂程度较低的核心资源着手，如:患者 资源、病症与诊断 资源家族史资源。

9.0.3 安全与隐私

临床资源往往表示的是与患者相关的数据，而正因为如此，它们也易于发生数据泄漏，或者说遭受数据安全突防行为侵害。 对于此类信息的搜索和获取，必须采取和落实必要的隐私与安全规定和防范措施。 关于更为通用的安全考虑，请参阅隐私与安全组件（Security and Privacy module）。

9.0.4 Common use Cases

  • Documenting a patient's condition - The Condition Resource is used extensively throughout FHIR Resources to associate information and activities with specific conditions. The Condition Resource is broadly defined to include problems, diagnoses and health concerns.
  • Retrieving the patient's problems
  • Documenting and retrieving the patient's allergies - The AllergyIntolerance Resource is used to represent the patient's allergy or intolerance to a substance. There is vibrant debate within clinical community regarding what is appropriate to document as an allergy or intolerance. These terms are used both formally by the Allergy and Immunology community as well as informally by patients leading to confusion. Readers are referred to the Resource definition for the Scope and Usage of this resource. The AllergyIntolerance Resource also supports the documenting of the absence of an allergy.
  • Family History - The FamilyMemberHistory Resource can be used to document known conditions of family members and support the creation of pedigrees.
  • Care Plans - The CarePlan resource supports a problem based care plan with references to other Resources including CareTeam, Condition, Goal, and activities such as ServiceRequest

9.0.5 Developmental Roadmap

Over the next 18 months, we will continue to advance the resources through the Maturity Levels through the process of development and testing of the Resources. We anticipate more widespread implementation of core Resources such as Condition. Complex Resources such as CarePlan are dependent on the maturation of its referred Resources and are expected to mature more gradually. The clinical community will need to develop use cases to test and further mature the ServiceRequest Resource at opportunities such as the Clinicians on FHIR sessions at the HL7 Working Group Meetings.