HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.6.0 - Draft for Community Review Viet Nam cờ

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Draft for Community Review (v0.6.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Hồ sơ tài nguyên: Nhận định lâm sàng VN Core — VN Core ClinicalImpression Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression Phiên bản: 0.6.0
Computable Name: VNCoreClinicalImpression

Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: TT 13/2025/TT-BYT ngày 06/06/2025.

Profile ClinicalImpression ghi nhận hợp lý/nhận định lâm sàng của bác sĩ trong một lượt khám (đánh giá tổng hợp, biện luận chẩn đoán, tiên lượng). Bổ trợ cho Condition (chẩn đoán) bằng phần biện luận. Căn cứ pháp lý:

  • TT 13/2025/TT-BYT — bệnh án điện tử (nhận định/biện luận lâm sàng). / VN Core ClinicalImpression for clinical reasoning/assessment.

Usages:

You can also check for usages in the FHIR IG Statistics

Các dạng xem hình thức của nội dung hồ sơ

Mô tả profile, differential, snapshot và các biểu diễn liên quan.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái: in-progress, completed, entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... effective[x] SΣ 0..1 Thời điểm/khoảng nhận định
.... effectiveDateTime dateTime
.... effectivePeriod Period
... assessor SΣ 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... status S 1..1 code Trạng thái: in-progress, completed, entered-in-error
... subject S 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh được nhận định
... encounter S 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... assessor S 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Trạng thái: in-progress, completed, entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 0..1 CodeableConcept Kind of assessment performed
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description Σ 0..1 string Why/how the assessment was performed
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh được nhận định
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... effective[x] SΣ 0..1 Thời điểm/khoảng nhận định
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor SΣ 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
.... itemReference 0..1 Reference(Condition | Observation | Media) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation Comments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái: in-progress, completed, entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... effective[x] SΣ 0..1 Thời điểm/khoảng nhận định
.... effectiveDateTime dateTime
.... effectivePeriod Period
... assessor SΣ 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem Differential

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... status S 1..1 code Trạng thái: in-progress, completed, entered-in-error
... subject S 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh được nhận định
... encounter S 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... assessor S 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)

doco Documentation for this format

Dạng xem SnapshotView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Trạng thái: in-progress, completed, entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code Σ 0..1 CodeableConcept Kind of assessment performed
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description Σ 0..1 string Why/how the assessment was performed
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh được nhận định
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... effective[x] SΣ 0..1 Thời điểm/khoảng nhận định
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor SΣ 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) Bác sĩ nhận định
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary S 0..1 string Tóm tắt biện luận lâm sàng
... finding S 0..* BackboneElement Phát hiện/kết luận (tham chiếu Condition/Observation)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
.... itemReference 0..1 Reference(Condition | Observation | Media) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation Comments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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