A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Mã định danh tài liệu/bệnh án tại cơ sở KCB. Cardinality 1..1 và tính duy nhất trong namespace là quy tắc tuân thủ VN Core để liên thông; TT 13/2025/TT-BYT không quy định trực tiếp Composition.identifier hoặc cardinality FHIR này.

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

preliminary (đang lập) | final (hoàn thành) | amended (sửa đổi) | entered-in-error (nhập nhầm).

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

The workflow/clinical status of the composition.

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Loại tài liệu y tế: bệnh án ngoại trú, nội trú, cấp cứu, v.v. Sử dụng LOINC Document Ontology.

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Type of a composition.

Key metadata element describing the composition, used in searching/filtering.

Người bệnh của tài liệu, tham chiếu VNCorePatient. TT 13/2025/TT-BYT Điều 1 khoản 3 yêu cầu kết nối thông tin bệnh án điện tử với số định danh cá nhân/tài khoản định danh điện tử trong phạm vi áp dụng; profile Composition này không tự chứng minh Patient có CCCD.

For clinical documents, this is usually the patient.

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Đợt khám bệnh hoặc điều trị nội trú liên quan.

Provides context for the composition and supports searching.

Thời điểm lập bệnh án, phục vụ audit trail và quản trị/chia sẻ dữ liệu y tế số. NĐ 102/2025/NĐ-CP là căn cứ dữ liệu y tế; NĐ 137/2024/NĐ-CP chỉ áp dụng thêm khi giao dịch nằm trong phạm vi cơ quan nhà nước.

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Nhân viên y tế chịu trách nhiệm lập bệnh án. Trong dữ liệu hiện hành nên liên kết tới Practitioner có GPHN; có thể giữ CCHN như định danh lịch sử khi chuyển đổi hồ sơ cũ.

Identifies who is responsible for the content.

Tiêu đề bệnh án (VD: 'Bệnh án ngoại trú', 'Bệnh án nội trú').

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Mức bảo mật tài liệu. Dữ liệu y tế = DLCN nhạy cảm theo Luật 91/2025/QH15 Điều 2 khoản 3; danh mục nhạy cảm gồm tình trạng sức khoẻ tại NĐ 356/2025/NĐ-CP Điều 4 khoản 1 điểm d.

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Codes specifying the level of confidentiality of the composition.

Nhân viên y tế, người bệnh hoặc người đại diện thực hiện ký/xác nhận điện tử theo TT 13/2025/TT-BYT Điều 3. Composition.attester ghi CHỦ THỂ xác nhận; nó không chứa và không thay thế chữ ký số — chữ ký số đi theo Provenance hoặc Bundle.signature.

Only list each attester once.

Identifies responsibility for the accuracy of the composition content.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of attestation the authenticator offers.

The way in which a person authenticated a composition.

Indicates the level of authority of the attestation.

When the composition was attested by the party.

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Who attested the composition in the specified way.

Identifies who has taken on the responsibility for accuracy of the composition content.

Cơ sở KCB chịu trách nhiệm lưu trữ tài liệu. Composition.custodian 1..1 là carrier VN Core hỗ trợ nghĩa vụ quản lý/lưu trữ; TT 13/2025/TT-BYT không quy định trực tiếp đường FHIR hoặc cardinality này.

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Identifies where to go to find the current version, where to report issues, etc.

Phân mục bệnh án: tiền sử, khám lâm sàng, chẩn đoán, xét nghiệm, điều trị, ra viện. Cấu trúc phân mục hỗ trợ chia sẻ dữ liệu tài liệu y tế theo NĐ 102/2025/NĐ-CP và NĐ 278/2025/NĐ-CP.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Nội dung dạng narrative (XHTML) cho phần này.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

If there are no entries in the list, an emptyReason SHOULD be provided.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Lý do đến khám' (ngoại trú), 'Lý do nhập viện' (nội trú), 'Lý do vào cấp cứu' (cấp cứu)

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Tiền sử bệnh', 'Tiền sử bệnh tật và dị ứng'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Khám lâm sàng', 'Khám thực thể'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Chẩn đoán', 'Chẩn đoán xác định'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

If there are no entries in the list, an emptyReason SHOULD be provided.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Kết quả cận lâm sàng', 'Xét nghiệm và chẩn đoán hình ảnh'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

If there are no entries in the list, an emptyReason SHOULD be provided.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Thuốc điều trị', 'Y lệnh dùng thuốc', 'Đơn thuốc'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

If there are no entries in the list, an emptyReason SHOULD be provided.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Thủ thuật / Phẫu thuật', 'Phẫu thuật đã thực hiện', 'Thủ thuật'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

If there are no entries in the list, an emptyReason SHOULD be provided.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Gợi ý: 'Tóm tắt ra viện', 'Tình trạng xuất viện và hướng xử trí'

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Mã LOINC xác định loại phần trong bệnh án.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

Mã định danh tài liệu/bệnh án tại cơ sở KCB. Cardinality 1..1 và tính duy nhất trong namespace là quy tắc tuân thủ VN Core để liên thông; TT 13/2025/TT-BYT không quy định trực tiếp Composition.identifier hoặc cardinality FHIR này.

preliminary (đang lập) | final (hoàn thành) | amended (sửa đổi) | entered-in-error (nhập nhầm).

Loại tài liệu y tế: bệnh án ngoại trú, nội trú, cấp cứu, v.v. Sử dụng LOINC Document Ontology.

Người bệnh của tài liệu, tham chiếu VNCorePatient. TT 13/2025/TT-BYT Điều 1 khoản 3 yêu cầu kết nối thông tin bệnh án điện tử với số định danh cá nhân/tài khoản định danh điện tử trong phạm vi áp dụng; profile Composition này không tự chứng minh Patient có CCCD.

Đợt khám bệnh hoặc điều trị nội trú liên quan.

Thời điểm lập bệnh án, phục vụ audit trail và quản trị/chia sẻ dữ liệu y tế số. NĐ 102/2025/NĐ-CP là căn cứ dữ liệu y tế; NĐ 137/2024/NĐ-CP chỉ áp dụng thêm khi giao dịch nằm trong phạm vi cơ quan nhà nước.

Nhân viên y tế chịu trách nhiệm lập bệnh án. Trong dữ liệu hiện hành nên liên kết tới Practitioner có GPHN; có thể giữ CCHN như định danh lịch sử khi chuyển đổi hồ sơ cũ.

Tiêu đề bệnh án (VD: 'Bệnh án ngoại trú', 'Bệnh án nội trú').

Mức bảo mật tài liệu. Dữ liệu y tế = DLCN nhạy cảm theo Luật 91/2025/QH15 Điều 2 khoản 3; danh mục nhạy cảm gồm tình trạng sức khoẻ tại NĐ 356/2025/NĐ-CP Điều 4 khoản 1 điểm d.

Nhân viên y tế, người bệnh hoặc người đại diện thực hiện ký/xác nhận điện tử theo TT 13/2025/TT-BYT Điều 3. Composition.attester ghi CHỦ THỂ xác nhận; nó không chứa và không thay thế chữ ký số — chữ ký số đi theo Provenance hoặc Bundle.signature.

Cơ sở KCB chịu trách nhiệm lưu trữ tài liệu. Composition.custodian 1..1 là carrier VN Core hỗ trợ nghĩa vụ quản lý/lưu trữ; TT 13/2025/TT-BYT không quy định trực tiếp đường FHIR hoặc cardinality này.

Phân mục bệnh án: tiền sử, khám lâm sàng, chẩn đoán, xét nghiệm, điều trị, ra viện. Cấu trúc phân mục hỗ trợ chia sẻ dữ liệu tài liệu y tế theo NĐ 102/2025/NĐ-CP và NĐ 278/2025/NĐ-CP.

Mã LOINC xác định loại phần trong bệnh án.

Nội dung dạng narrative (XHTML) cho phần này.

Các FHIR resource liên quan: Condition, Observation, MedicationRequest, Procedure, v.v.

Gợi ý: 'Lý do đến khám' (ngoại trú), 'Lý do nhập viện' (nội trú), 'Lý do vào cấp cứu' (cấp cứu)

Gợi ý: 'Tiền sử bệnh', 'Tiền sử bệnh tật và dị ứng'

Gợi ý: 'Khám lâm sàng', 'Khám thực thể'

Gợi ý: 'Chẩn đoán', 'Chẩn đoán xác định'

Gợi ý: 'Kết quả cận lâm sàng', 'Xét nghiệm và chẩn đoán hình ảnh'

Gợi ý: 'Thuốc điều trị', 'Y lệnh dùng thuốc', 'Đơn thuốc'

Gợi ý: 'Thủ thuật / Phẫu thuật', 'Phẫu thuật đã thực hiện', 'Thủ thuật'

Gợi ý: 'Tóm tắt ra viện', 'Tình trạng xuất viện và hướng xử trí'

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Mã định danh tài liệu/bệnh án tại cơ sở KCB. Cardinality 1..1 và tính duy nhất trong namespace là quy tắc tuân thủ VN Core để liên thông; TT 13/2025/TT-BYT không quy định trực tiếp Composition.identifier hoặc cardinality FHIR này.

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

preliminary (đang lập) | final (hoàn thành) | amended (sửa đổi) | entered-in-error (nhập nhầm).

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

The workflow/clinical status of the composition.

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Loại tài liệu y tế: bệnh án ngoại trú, nội trú, cấp cứu, v.v. Sử dụng LOINC Document Ontology.

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Type of a composition.

Key metadata element describing the composition, used in searching/filtering.

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

This is a metadata field from XDS/MHD.

High-level kind of a clinical document at a macro level.

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Người bệnh của tài liệu, tham chiếu VNCorePatient. TT 13/2025/TT-BYT Điều 1 khoản 3 yêu cầu kết nối thông tin bệnh án điện tử với số định danh cá nhân/tài khoản định danh điện tử trong phạm vi áp dụng; profile Composition này không tự chứng minh Patient có CCCD.

For clinical documents, this is usually the patient.

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Đợt khám bệnh hoặc điều trị nội trú liên quan.

Provides context for the composition and supports searching.

Thời điểm lập bệnh án, phục vụ audit trail và quản trị/chia sẻ dữ liệu y tế số. NĐ 102/2025/NĐ-CP là căn cứ dữ liệu y tế; NĐ 137/2024/NĐ-CP chỉ áp dụng thêm khi giao dịch nằm trong phạm vi cơ quan nhà nước.

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Nhân viên y tế chịu trách nhiệm lập bệnh án. Trong dữ liệu hiện hành nên liên kết tới Practitioner có GPHN; có thể giữ CCHN như định danh lịch sử khi chuyển đổi hồ sơ cũ.

Identifies who is responsible for the content.

Tiêu đề bệnh án (VD: 'Bệnh án ngoại trú', 'Bệnh án nội trú').

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Mức bảo mật tài liệu. Dữ liệu y tế = DLCN nhạy cảm theo Luật 91/2025/QH15 Điều 2 khoản 3; danh mục nhạy cảm gồm tình trạng sức khoẻ tại NĐ 356/2025/NĐ-CP Điều 4 khoản 1 điểm d.

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Codes specifying the level of confidentiality of the composition.

Nhân viên y tế, người bệnh hoặc người đại diện thực hiện ký/xác nhận điện tử theo TT 13/2025/TT-BYT Điều 3. Composition.attester ghi CHỦ THỂ xác nhận; nó không chứa và không thay thế chữ ký số — chữ ký số đi theo Provenance hoặc Bundle.signature.

Only list each attester once.

Identifies responsibility for the accuracy of the composition content.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of attestation the authenticator offers.

The way in which a person authenticated a composition.

Indicates the level of authority of the attestation.

When the composition was attested by the party.

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Who attested the composition in the specified way.

Identifies who has taken on the responsibility for accuracy of the composition content.

Cơ sở KCB chịu trách nhiệm lưu trữ tài liệu. Composition.custodian 1..1 là carrier VN Core hỗ trợ nghĩa vụ quản lý/lưu trữ; TT 13/2025/TT-BYT không quy định trực tiếp đường FHIR hoặc cardinality này.

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Identifies where to go to find the current version, where to report issues, etc.

Relationships that this composition has with other compositions or documents that already exist.

A document is a version specific composition.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of relationship that this composition has with anther composition or document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The type of relationship between documents.

The target composition/document of this relationship.