HL7 Vietnam VN Core FHIR Implementation Guide

Hướng dẫn triển khai FHIR cốt lõi Việt Nam — VN Core FHIR Implementation Guide
0.10.0 - Draft for Community Review Viet Nam cờ

Hướng dẫn triển khai FHIR cốt lõi Việt Nam — VN Core FHIR Implementation Guide - Draft for Community Review (v0.10.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Hồ sơ tài nguyên: Giấy chứng sinh — VN Core Birth Certificate Composition

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition-birth-certificate Phiên bản: 0.10.0
Computable Name: VNCoreCompositionBirthCertificate
Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.39

Tài liệu Giấy chứng sinh do cơ sở khám bệnh, chữa bệnh cấp theo QĐ 2919/QĐ-BYT (hiệu lực 01/10/2025), trường hợp sinh thường.

Vì sao là Composition chứ không phải DocumentReference đơn thuần. Giấy chứng sinh là dữ liệu CÓ CẤU TRÚC được liên thông sang Phần mềm dịch vụ công theo NĐ 63/2024/NĐ-CP, không chỉ là một tệp đính kèm. Composition giữ phần đầu tài liệu và các tham chiếu có cấu trúc (trẻ, mẹ, cơ sở, người ký); bản PDF/XML đã ký số nằm ở VNCoreDocumentReferenceBirthCertificate.

Định danh dùng sid/gcs, KHÔNG dùng sid/gks. Giấy chứng sinh do cơ sở khám bệnh, chữa bệnh cấp ngay sau sinh; Giấy khai sinh do Uỷ ban nhân dân cấp sau đó theo thủ tục hộ tịch. Khác cơ quan cấp, khác thời điểm, khác cấu trúc số — xem VNGCSNS.

Chưa khoá mã loại tài liệu. type dùng text = "Giấy chứng sinh"; QĐ 2919/QĐ-BYT không ban hành mã loại tài liệu, và tự đặt một mã rồi trình bày như mã pháp định là điều IG này tránh. Phân biệt sinh thường với mang thai hộ dựa vào profile, không dựa vào mã.

Trường hợp mang thai hộ dùng profile riêng VNCoreCompositionSurrogacyBirthCertificate: schema Phụ lục II có bốn bên (vợ/chồng bên nhờ mang thai hộ, vợ/chồng bên mang thai hộ) chứ không phải một người mẹ, nên author/attester/tham chiếu chủ thể khác hẳn.

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
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester, vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... system SΣ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value SΣ 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
Example General: 123456
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... text SΣ 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Trẻ được cấp giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... date SOΣ 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... title SOΣ 1..1 string Tên tài liệu — ghi Giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... attester SO 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time S 0..1 dateTime Thời điểm ký/xác nhận điện tử
.... party S 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian SOΣ 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... Slices for section SOC 2..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint Narrative - Reported
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:history SOC 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Past illness note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:physicalExam SOC 0..1 BackboneElement Kết quả khám lâm sàng
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 1..1 string Representation defined by the system
Fixed Value: Physical findings note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:diagnosis SOC 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29548-5
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnosis Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 1..1 string Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Medication use Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 1..1 string Representation defined by the system
Fixed Value: History of Procedures Document
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18842-5
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:mother SOC 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... entry SC 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
.... section:birthFacts SOC 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... entry SC 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:history.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))
vn-composition-final-requires-attester error Composition Tài liệu ở trạng thái final hoặc amended phải có ít nhất một người ký/xác nhận điện tử. A composition in final or amended status SHALL carry at least one attester. status.exists() and (status = 'final' or status = 'amended') implies attester.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) section:birthFacts.entry
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... identifier 1..1 Identifier Mã giấy chứng sinh (MA_GCS)
.... system S 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value S 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
... type
.... text S 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... date 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
... author 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
... title 1..1 string Tên tài liệu — ghi Giấy chứng sinh
... attester 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
.... party 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
... section 2..* BackboneElement Các phần bệnh án
... Slices for section Content/Rules for all slices
.... section:mother S 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
..... title 1..1 string Tên phần
..... code 1..1 CodeableConcept Mã phần (LOINC)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
..... entry S 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
.... section:birthFacts S 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
..... title 1..1 string Tên phần
..... code 1..1 CodeableConcept Mã phần (LOINC)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
..... entry S 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... Slices for section

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester, vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
... 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
... 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
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã giấy chứng sinh (MA_GCS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system SΣ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value SΣ 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
.... text SΣ 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Trẻ được cấp giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... date SOΣ 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... title SOΣ 1..1 string Tên tài liệu — ghi Giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... attester SO 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... 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
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time S 0..1 dateTime Thời điểm ký/xác nhận điện tử
.... party S 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian SOΣ 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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 Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SOC 2..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... section:All Slices Content/Rules for all slices
..... 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
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint Narrative - Reported
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:history SOC 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Past illness note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:physicalExam SOC 0..1 BackboneElement Kết quả khám lâm sàng
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 1..1 string Representation defined by the system
Fixed Value: Physical findings note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:diagnosis SOC 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29548-5
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnosis Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 1..1 string Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Medication use Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 1..1 string Representation defined by the system
Fixed Value: History of Procedures Document
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18842-5
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:mother SOC 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry SC 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:birthFacts SOC 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry SC 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.2
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:history.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:history.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:history.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:history.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:labResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:labResults.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:medications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:medications.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:procedures.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:procedures.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:mother.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:mother.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))
vn-composition-final-requires-attester error Composition Tài liệu ở trạng thái final hoặc amended phải có ít nhất một người ký/xác nhận điện tử. A composition in final or amended status SHALL carry at least one attester. status.exists() and (status = 'final' or status = 'amended') implies attester.exists()
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester, vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... system SΣ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value SΣ 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
Example General: 123456
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... text SΣ 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Trẻ được cấp giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... date SOΣ 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... title SOΣ 1..1 string Tên tài liệu — ghi Giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... attester SO 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time S 0..1 dateTime Thời điểm ký/xác nhận điện tử
.... party S 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian SOΣ 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... Slices for section SOC 2..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint Narrative - Reported
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:history SOC 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Past illness note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:physicalExam SOC 0..1 BackboneElement Kết quả khám lâm sàng
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 1..1 string Representation defined by the system
Fixed Value: Physical findings note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:diagnosis SOC 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29548-5
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnosis Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 1..1 string Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Medication use Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 1..1 string Representation defined by the system
Fixed Value: History of Procedures Document
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18842-5
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
.... section:mother SOC 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... entry SC 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
.... section:birthFacts SOC 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... entry SC 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:history.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))
vn-composition-final-requires-attester error Composition Tài liệu ở trạng thái final hoặc amended phải có ít nhất một người ký/xác nhận điện tử. A composition in final or amended status SHALL carry at least one attester. status.exists() and (status = 'final' or status = 'amended') implies attester.exists()

Dạng xem Differential

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... identifier 1..1 Identifier Mã giấy chứng sinh (MA_GCS)
.... system S 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value S 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
... type
.... text S 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... date 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
... author 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
... title 1..1 string Tên tài liệu — ghi Giấy chứng sinh
... attester 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
.... party 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
... section 2..* BackboneElement Các phần bệnh án
... Slices for section Content/Rules for all slices
.... section:mother S 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
..... title 1..1 string Tên phần
..... code 1..1 CodeableConcept Mã phần (LOINC)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
..... entry S 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
.... section:birthFacts S 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
..... title 1..1 string Tên phần
..... code 1..1 CodeableConcept Mã phần (LOINC)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
..... entry S 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... Slices for section

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))

Dạng xem SnapshotView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* VNCoreComposition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester, vn-birth-certificate-gcs-identifier
ObligationsActorElements
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​attester
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​author
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​custodian
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​date
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.system
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​identifier.value
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​status
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​subject
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​type.text
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:mother.entry
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.code
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.title
SHALL:no-error Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway) ​section:birthFacts.entry
... 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
... 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
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:issueOrdinal SO 1..1 code Lần cấp (LAN_CAP): 0 cấp lần đầu, 1 cấp lại
URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-birth-certificate-issue-ordinal
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Cổng liên thông thủ tục hành chính (e-Service Gateway)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã giấy chứng sinh (MA_GCS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system SΣ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.hl7.org.vn/core/sid/gcs
.... value SΣ 1..1 string 18 ký tự dạng XXXXX.GCS.ZZZZZ.YY
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
.... text SΣ 1..1 string Plain text representation of the concept
Fixed Value: Giấy chứng sinh
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Trẻ được cấp giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... date SOΣ 1..1 dateTime Ngày cấp giấy chứng sinh (NGAY_CS)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người đỡ đẻ hoặc cơ sở khám bệnh, chữa bệnh lập giấy
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... title SOΣ 1..1 string Tên tài liệu — ghi Giấy chứng sinh
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... attester SO 1..* BackboneElement Người đứng đầu cơ sở KBCB hoặc người được uỷ quyền ký (THU_TRUONG_DVI)
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... 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
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time S 0..1 dateTime Thời điểm ký/xác nhận điện tử
.... party S 1..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Chủ thể xác nhận — nhân viên y tế, người bệnh, người đại diện hoặc tổ chức
... custodian SOΣ 1..1 Reference(Cơ sở khám bệnh, chữa bệnh VN Core — VN Core KCB Organization Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở khám bệnh, chữa bệnh cấp giấy — giữ bản gốc
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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 Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SOC 2..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
.... section:All Slices Content/Rules for all slices
..... 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
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint Narrative - Reported
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:history SOC 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Past illness note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:physicalExam SOC 0..1 BackboneElement Kết quả khám lâm sàng
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
....... display 1..1 string Representation defined by the system
Fixed Value: Physical findings note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:diagnosis SOC 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29548-5
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnosis Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
....... display 1..1 string Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data note
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 1..1 string Representation defined by the system
Fixed Value: History of Medication use Narrative
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
....... display 1..1 string Representation defined by the system
Fixed Value: History of Procedures Document
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 0..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18842-5
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:mother SOC 1..1 BackboneElement Thông tin người mẹ — trỏ RelatedPerson, cùng trẻ với subject
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-mother
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry SC 1..1 Reference(Người liên quan/người giám hộ VN Core — VN Core RelatedPerson Profile) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:birthFacts SOC 1..1 BackboneElement Chỉ số lúc sinh — tối thiểu cân nặng (ô bắt buộc của mẫu giấy chứng sinh)
Constraints: cmp-1, cmp-2
ObligationsActorSource
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) from Bệnh án điện tử VN Core — VN Core Composition Profile
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository) from Bệnh án điện tử VN Core — VN Core Composition Profile
..... 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
..... title S 1..1 string Tên phần
..... code S 1..1 CodeableConcept Mã phần (LOINC)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-composition-section-cs
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: birth-facts
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 0..1 Narrative Nội dung tường thuật
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry SC 1..* Reference(Cân nặng VN Core — VN Core Observation Body Weight Profile | Observation) Tài nguyên liên quan
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.2
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:chiefComplaint.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:history.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:history.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:history.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:history.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:physicalExam.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:diagnosis.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:labResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:labResults.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:labResults.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:medications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:medications.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:medications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:procedures.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:procedures.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:procedures.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:dischargeSummary.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:mother.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:mother.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:mother.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:birthFacts.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary, Composition.section:mother, Composition.section:birthFacts A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
vn-birth-certificate-gcs-identifier error Composition Mã giấy chứng sinh phải đúng dạng XXXXX.GCS.ZZZZZ.YY. The birth certificate identifier SHALL follow the published pattern. identifier.where(system = 'http://fhir.hl7.org.vn/core/sid/gcs').value.all(matches('^[0-9]{5}\\.GCS\\.[0-9]{5}\\.[0-9]{2}$'))
vn-composition-final-requires-attester error Composition Tài liệu ở trạng thái final hoặc amended phải có ít nhất một người ký/xác nhận điện tử. A composition in final or amended status SHALL carry at least one attester. status.exists() and (status = 'final' or status = 'amended') implies attester.exists()
NameKho hồ sơ EMR (Repository)Cổng liên thông thủ tục hành chính (e-Service Gateway)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... Slices for extension
.... extension:issueOrdinal
... identifier
... status
... subject
... encounter
... date
... author
... title
... confidentiality
... attester
... custodian
... Slices for section
.... section:All Slices
.... section:chiefComplaint
.... section:history
.... section:physicalExam
.... section:diagnosis
.... section:labResults
.... section:medications
.... section:procedures
.... section:dischargeSummary
.... section:mother
.... section:birthFacts

doco Documentation for this format

 

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