HL7 Vietnam VN Core FHIR Implementation Guide

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

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

Hồ sơ tài nguyên: Tiền sử dùng thuốc VN Core — VN Core MedicationStatement Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-medication-statement Phiên bản: 0.6.0
Computable Name: VNCoreMedicationStatement

Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: TT 13/2025/TT-BYT ngày 06/06/2025; Luật Dược 105/2016/QH13 Điều 74; Luật 44/2024/QH15.

Profile MedicationStatement ghi nhận tiền sử/đang dùng thuốc của người bệnh (khai thác bệnh sử khi tiếp nhận ngoại trú/nội trú). Khác MedicationRequest (y lệnh mới) và MedicationDispense (cấp phát) — đây là ghi nhận thuốc người bệnh khai/đang dùng. Căn cứ pháp lý:

  • TT 13/2025/TT-BYT — bệnh án điện tử (tiền sử dùng thuốc)
  • Luật Dược 105/2016/QH13 + Luật 44/2024/QH15 — quản lý thông tin thuốc. / VN Core MedicationStatement for recording patient-reported/current medication history.

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
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... context SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khai thác tiền sử
... effective[x] SΣ 0..1 Thời điểm/khoảng thời gian dùng thuốc
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
MedicationStatement.​status Base required Medication status codes 📍4.0.1 FHIR Std.
MedicationStatement.​medication[x] Base example SNOMED CT Medication Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error MedicationStatement If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error MedicationStatement 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 MedicationStatement 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 MedicationStatement If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice MedicationStatement A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... status S 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
... medication[x] S 1..1 CodeableConcept Thuốc người bệnh đang/đã dùng (ATC / mã thuốc / text)
... subject S 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... effective[x] S 0..1 dateTime, Period Thời điểm/khoảng thời gian dùng thuốc
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External identifier
... basedOn Σ 0..* Reference(MedicationRequest | CarePlan | ServiceRequest) Fulfils plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) Part of referenced event
... status ?!SΣ 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
... statusReason 0..* CodeableConcept Reason for current status
Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.
... category Σ 0..1 CodeableConcept Type of medication usage
Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.
... medication[x] SΣ 1..1 CodeableConcept Thuốc người bệnh đang/đã dùng (ATC / mã thuốc / text)
Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... context SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khai thác tiền sử
... effective[x] SΣ 0..1 Thời điểm/khoảng thời gian dùng thuốc
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dateAsserted Σ 0..1 dateTime When the statement was asserted?
... informationSource 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) Person or organization that provided the information about the taking of this medication
... derivedFrom 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* CodeableConcept Reason for why the medication is being/was taken
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.
... reasonReference 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication is being/was taken
... note 0..* Annotation Further information about the statement
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
MedicationStatement.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
MedicationStatement.​status Base required Medication status codes 📍4.0.1 FHIR Std.
MedicationStatement.​statusReason Base example SNOMED CT Drug Therapy Status codes 📍4.0.1 FHIR Std.
MedicationStatement.​category Base preferred Medication usage category codes 📍4.0.1 FHIR Std.
MedicationStatement.​medication[x] Base example SNOMED CT Medication Codes 📍4.0.1 FHIR Std.
MedicationStatement.​reasonCode Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error MedicationStatement If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error MedicationStatement 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 MedicationStatement 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 MedicationStatement If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice MedicationStatement A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... context SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khai thác tiền sử
... effective[x] SΣ 0..1 Thời điểm/khoảng thời gian dùng thuốc
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
MedicationStatement.​status Base required Medication status codes 📍4.0.1 FHIR Std.
MedicationStatement.​medication[x] Base example SNOMED CT Medication Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error MedicationStatement If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error MedicationStatement 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 MedicationStatement 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 MedicationStatement If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice MedicationStatement A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Dạng xem Differential

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... status S 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
... medication[x] S 1..1 CodeableConcept Thuốc người bệnh đang/đã dùng (ATC / mã thuốc / text)
... subject S 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... effective[x] S 0..1 dateTime, Period Thời điểm/khoảng thời gian dùng thuốc
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format

Dạng xem SnapshotView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationStatement 0..* MedicationStatement Record of medication being taken by a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External identifier
... basedOn Σ 0..* Reference(MedicationRequest | CarePlan | ServiceRequest) Fulfils plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) Part of referenced event
... status ?!SΣ 1..1 code Trạng thái: active, completed, intended, stopped, on-hold...
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.
... statusReason 0..* CodeableConcept Reason for current status
Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.
... category Σ 0..1 CodeableConcept Type of medication usage
Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.
... medication[x] SΣ 1..1 CodeableConcept Thuốc người bệnh đang/đã dùng (ATC / mã thuốc / text)
Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Người bệnh
... context SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khai thác tiền sử
... effective[x] SΣ 0..1 Thời điểm/khoảng thời gian dùng thuốc
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dateAsserted Σ 0..1 dateTime When the statement was asserted?
... informationSource 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) Person or organization that provided the information about the taking of this medication
... derivedFrom 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* CodeableConcept Reason for why the medication is being/was taken
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.
... reasonReference 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication is being/was taken
... note 0..* Annotation Further information about the statement
... dosage S 0..* Dosage Cách dùng theo lời khai

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
MedicationStatement.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
MedicationStatement.​status Base required Medication status codes 📍4.0.1 FHIR Std.
MedicationStatement.​statusReason Base example SNOMED CT Drug Therapy Status codes 📍4.0.1 FHIR Std.
MedicationStatement.​category Base preferred Medication usage category codes 📍4.0.1 FHIR Std.
MedicationStatement.​medication[x] Base example SNOMED CT Medication Codes 📍4.0.1 FHIR Std.
MedicationStatement.​reasonCode Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error MedicationStatement If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error MedicationStatement 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 MedicationStatement 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 MedicationStatement If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice MedicationStatement A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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