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: Bệnh án điện tử VN Core — VN Core Composition Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition Phiên bản: 0.10.0
Computable Name: VNCoreComposition
Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.45

Profile Composition cho bệnh án điện tử (EMR) Việt Nam. Cấu trúc tài liệu y tế có phân mục: tiền sử, chẩn đoán, xét nghiệm, điều trị, ra viện. Căn cứ:

  • Luật 20/2023/QH15 — Luật Giao dịch điện tử, đọc theo sửa đổi tại Luật 60/2024/QH15
  • Luật 60/2024/QH15 — Luật Dữ liệu, nền tảng quản trị dữ liệu số
  • TT 13/2025/TT-BYT — 06/6/2025 — bệnh án điện tử, hiệu lực 21/7/2025
  • TT 38/2024/TT-BYT — 16/11/2024 (hiệu lực 01/01/2027, chưa áp dụng) — hệ thống thông tin quản lý hoạt động KCB
  • NĐ 102/2025/NĐ-CP — 13/5/2025 — quản lý dữ liệu y tế số
  • NĐ 278/2025/NĐ-CP — ban hành 22/10/2025, hiệu lực từ ngày ký 22/10/2025 — kết nối, chia sẻ dữ liệu bắt buộc giữa cơ quan thuộc hệ thống chính trị; mốc chuẩn hoá/kết nối thống nhất chậm nhất 31/12/2026
  • QĐ 11/2026/QĐ-TTg — 28/3/2026 — danh mục CSDL quốc gia, bao gồm CSDL quốc gia về y tế
  • NĐ 23/2025/NĐ-CP — chữ ký điện tử và dịch vụ tin cậy
  • NĐ 68/2024/NĐ-CP — áp dụng khi cơ sở y tế công lập dùng chữ ký số chuyên dùng công vụ
  • NĐ 137/2024/NĐ-CP — chỉ khi giao dịch thuộc phạm vi cơ quan nhà nước/hệ thống thông tin phục vụ giao dịch điện tử
  • Luật KCB 2023 — hồ sơ bệnh án.

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..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SOΣ 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SOΣ 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... Slices for section SOC 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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.
..... 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
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... 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
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
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.

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 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 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-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..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... identifier SO 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... status SO 1..1 code Trạng thái
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SO 1..1 CodeableConcept Loại bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SO 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SO 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SO 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SO 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SO 0..1 code Mức bảo mật
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 SO 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... Slices for section SO 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... section:All Slices Content/Rules for all slices
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
..... text 0..1 Narrative Nội dung tường thuật
..... entry 0..* Reference(Resource) Tài nguyên liên quan
.... section:chiefComplaint SO 0..1 BackboneElement Lý do đến khám / nhập viện
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:history SO 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:physicalExam SO 0..1 BackboneElement Kết quả khám lâm sàng
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:diagnosis SO 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
.... section:labResults SO 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 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
.... section:medications SO 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
.... section:procedures SO 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
.... section:dischargeSummary SO 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
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..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... 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) Bệnh nhân
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SOΣ 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SOΣ 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... 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 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

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.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.

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 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 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-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)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Summary

Mandatory: 3 elements(9 nested mandatory elements)
Must-Support: 25 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the values of Composition.section

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... subject SOΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SOΣ 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SOΣ 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... Slices for section SOC 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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.
..... 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
..... entry C 0..* Reference(Resource) Tài nguyên liên quan
.... section:chiefComplaint SOC 0..1 BackboneElement Lý do đến khám / nhập viện
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
.... section:labResults SOC 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... 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
.... section:medications SOC 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
.... section:procedures SOC 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
..... entry C 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
.... section:dischargeSummary SOC 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
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.

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 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 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-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..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... identifier SO 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... status SO 1..1 code Trạng thái
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SO 1..1 CodeableConcept Loại bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SO 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SO 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SO 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SO 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SO 0..1 code Mức bảo mật
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... mode S 1..1 code Tư cách xác nhận (personal | professional | legal | official)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 SO 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... Slices for section SO 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... section:All Slices Content/Rules for all slices
..... title S 0..1 string Tên phần
..... code S 0..1 CodeableConcept Mã phần (LOINC)
..... text 0..1 Narrative Nội dung tường thuật
..... entry 0..* Reference(Resource) Tài nguyên liên quan
.... section:chiefComplaint SO 0..1 BackboneElement Lý do đến khám / nhập viện
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:history SO 0..1 BackboneElement Tiền sử bệnh tật, dị ứng, gia đình
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:physicalExam SO 0..1 BackboneElement Kết quả khám lâm sàng
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
.... section:diagnosis SO 0..1 BackboneElement Chẩn đoán sơ bộ và xác định (ICD-10 VN)
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Chẩn đoán VN Core — VN Core Condition Profile) Tài nguyên liên quan
.... section:labResults SO 0..1 BackboneElement Kết quả xét nghiệm, chẩn đoán hình ảnh
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 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
.... section:medications SO 0..1 BackboneElement Đơn thuốc, y lệnh dùng thuốc
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile) Tài nguyên liên quan
.... section:procedures SO 0..1 BackboneElement Thủ thuật, phẫu thuật đã thực hiện
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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
..... entry 0..* Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile) Tài nguyên liên quan
.... section:dischargeSummary SO 0..1 BackboneElement Tình trạng ra viện, hướng điều trị tiếp
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... title 0..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://loinc.org
....... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
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()

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NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
Constraints: vn-composition-final-requires-attester
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SOΣ 1..1 Identifier Mã bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... status ?!SOΣ 1..1 code Trạng thái
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... type SOΣ 1..1 CodeableConcept Loại bệnh án
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... 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) Bệnh nhân
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... encounter SOΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Đợt khám/điều trị
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... date SOΣ 1..1 dateTime Ngày lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... author SOΣ 1..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Bác sĩ lập bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... title SOΣ 1..1 string Tiêu đề bệnh án
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... confidentiality SOΣ 0..1 code Mức bảo mật
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... attester SO 0..* BackboneElement Người ký hoặc xác nhận điện tử tài liệu
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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 | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Bệnh nhân VN Core — VN Core Patient Profile | Người liên quan/người giám hộ VN Core — VN Core RelatedPerson 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 y tế VN Core — VN Core Organization Profile) CSKCB lưu trữ
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
... 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 0..* BackboneElement Các phần bệnh án
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
.... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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
ObligationsActor
SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source)
SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
..... 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

doco Documentation for this format
NameKho hồ sơ EMR (Repository)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

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.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.

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 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 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-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)Nguồn tạo hồ sơ lâm sàng (Document Source)doco
.. Composition
... identifier
... status
... type
... 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

doco Documentation for this format

Summary

Mandatory: 3 elements(9 nested mandatory elements)
Must-Support: 25 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the values of Composition.section

 

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