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

Ví dụ Bundle: Ví dụ: Bundle xét nghiệm CBC + Sinh hoá — kết quả bất thường WBC

Bundle ExampleBundleLabOrderResult of type collection


Entry 1 - fullUrl = http://fhir.hl7.org.vn/core/Patient/ExamplePatientNguyenVanAn

Resource Patient:

Nguyễn Văn An Male, DoB: 1985-03-15 ( Căn cước công dân: VNCCCD#001085012345)


Other Ids:
  • Thẻ bảo hiểm y tế/0791234567
  • Mã bệnh nhân nội bộ/BV-CR-2026-001234
  • Mã số bảo hiểm xã hội/0791234567
Contact Detail
Dân tộc — Vietnam Ethnicity ExtensionKinh
Patient Birth PlacePhường Ngọc Hà, Hà Nội
Nghề nghiệp — Vietnam Occupation ExtensionNhà phân tích hệ thống
Patient ReligionCông giáo
Patient Citizenship:
  • code: Viet Nam

Entry 2 - fullUrl = http://fhir.hl7.org.vn/core/Practitioner/ExamplePractitionerBSCKII

Resource Practitioner:

identifier: Căn cước công dân/079175001234, Giấy phép hành nghề/001234/BYT-GPHN, Chứng chỉ hành nghề/HCM-001234/BYT-CCHN

name: Nguyễn Thị Lan

gender: Female

qualification

code: Bác sỹ

issuer: Bộ Y tế

qualification

code: Bác sĩ Chuyên khoa II — Nội khoa

issuer: Bộ Y tế


Entry 3 - fullUrl = http://fhir.hl7.org.vn/core/Organization/ExampleOrganizationChoRay

Resource Organization:

Loại hình cơ sở y tế — Vietnam Organization Type Extension: Bệnh viện

Cấp quản lý hành chính y tế — Vietnam Administrative Health Level Extension: Trung ương

Hạng cơ sở khám bệnh, chữa bệnh — Vietnam KCB Facility Rank Extension: Đặc biệt

Tình trạng xếp hạng cơ sở y tế — Organization Rank Status Extension: Đã xếp hạng

Cấp năng lực cơ sở KCB — Facility Care Level Extension: Cấp chuyên sâu

Dải điểm chất lượng cơ sở KCB — Quality Score Band Extension: Từ 70 điểm trở lên

identifier: Giấy phép hoạt động cơ sở KCB/203/BYT-GPHĐ (use: official, period: 2014-07-08 --> (ongoing)), Mã cơ sở khám chữa bệnh/79001

active: true

name: Bệnh viện Chợ Rẫy

Contacts

-TelecomAddress
*ph: 028 3855 4137201B Nguyễn Chí Thanh, Phường Chợ Lớn, Thành phố Hồ Chí Minh

Entry 4 - fullUrl = http://fhir.hl7.org.vn/core/Encounter/InlineEncounterOutpatientLab

Resource Encounter:

identifier: Mã lượt khám chữa bệnh/LK-2026-04-15-0318

status: completed

class: ambulatory

type: Khám ngoại trú — sốt + mệt mỏi, chỉ định XN tổng quát

subject: Nguyễn Văn An

serviceProvider: Bệnh viện Chợ Rẫy

participant


Entry 5 - fullUrl = http://fhir.hl7.org.vn/core/ServiceRequest/InlineServiceRequestCBCBiochem

Resource ServiceRequest:

status: Completed

intent: Order

category: Xét nghiệm

priority: Routine

code: No display for ServiceRequest.code (concept: CBC panel - Blood by Automated count)

orderDetail: No display for ServiceRequest.orderDetail ()

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

authoredOn: 2026-04-15 08:30:00+0700

requester: BS CKII Nguyễn Thị Lan

performer: Bệnh viện Chợ Rẫy

specimen:

note:

BN sốt 38.5°C, mệt mỏi, ăn kém 3 ngày. Không rõ ổ nhiễm trùng. Chỉ định XN tổng quát để định hướng chẩn đoán.

patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Nhịn ăn ít nhất 8 giờ trước khi lấy máu. Lấy máu tĩnh mạch khuỷu tay.)


Entry 6 - fullUrl = http://fhir.hl7.org.vn/core/Specimen/InlineSpecimenWholeBloodLab0415

Resource Specimen:

status: Available

type: Máu toàn phần (EDTA)

subject: Nguyễn Văn An

receivedTime: 2026-04-15 08:55:00+0700

request: ServiceRequest CBC panel - Blood by Automated count

Collections

-Collected[x]Quantity
*2026-04-15 08:45:00+07002 mL (Details: UCUM codemL = 'mL')

container


Entry 7 - fullUrl = http://fhir.hl7.org.vn/core/Specimen/InlineSpecimenSerumLab0415

Resource Specimen:

status: Available

type: Mẫu huyết thanh

subject: Nguyễn Văn An

receivedTime: 2026-04-15 08:55:00+0700

request: ServiceRequest CBC panel - Blood by Automated count

Collections

-Collected[x]Quantity
*2026-04-15 08:50:00+07004 mL (Details: UCUM codemL = 'mL')

container


Entry 8 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationWBC

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Bạch cầu (WBC)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 15.2 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')

interpretation: Cao

note:

Tăng bạch cầu (leukocytosis): WBC 15.2 × 10⁹/L. Gợi ý nhiễm trùng vi khuẩn cấp. Đề nghị CRP để đánh giá mức độ viêm.

specimen: Specimen: status = available; type = Whole blood; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*4 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')10 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')

4.0 – 10.0 ×10⁹/L


Entry 9 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationRBC

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Hồng cầu (RBC)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 4.8 ×10¹²/L (Details: UCUM code10*12/L = '10*12/L')

specimen: Specimen: status = available; type = Whole blood; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*4 ×10¹²/L (Details: UCUM code10*12/L = '10*12/L')5.5 ×10¹²/L (Details: UCUM code10*12/L = '10*12/L')

4.0 – 5.5 ×10¹²/L (nam)


Entry 10 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationHemoglobin

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Hemoglobin (Hgb)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 145 g/L (Details: UCUM codeg/L = 'g/L')

specimen: Specimen: status = available; type = Whole blood; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*130 g/L (Details: UCUM codeg/L = 'g/L')170 g/L (Details: UCUM codeg/L = 'g/L')

130 – 170 g/L (nam)


Entry 11 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationPlatelet

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Tiểu cầu (PLT)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 250 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')

specimen: Specimen: status = available; type = Whole blood; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*150 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')400 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')

150 – 400 ×10⁹/L


Entry 12 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationGlucoseLab

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Glucose máu lúc đói

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 5.4 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

specimen: Specimen: status = available; type = Serum; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*3.9 mmol/L (Details: UCUM codemmol/L = 'mmol/L')6.1 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

3.9 – 6.1 mmol/L


Entry 13 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationCreatinine

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: Creatinine huyết thanh

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 85 µmol/L (Details: UCUM codeumol/L = 'umol/L')

specimen: Specimen: status = available; type = Serum; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*62 µmol/L (Details: UCUM codeumol/L = 'umol/L')106 µmol/L (Details: UCUM codeumol/L = 'umol/L')

62 – 106 µmol/L (nam)


Entry 14 - fullUrl = http://fhir.hl7.org.vn/core/Observation/InlineObservationALT

Resource Observation:

basedOn: ServiceRequest CBC panel - Blood by Automated count

status: Final

category: Laboratory

code: ALT (SGPT)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

effective: 2026-04-15 09:00:00+0700

issued: 2026-04-15 10:30:00+0700

performer: Bệnh viện Chợ Rẫy

value: 32 U/L (Details: UCUM codeU/L = 'U/L')

specimen: Specimen: status = available; type = Serum; receivedTime = 2026-04-15 08:55:00+0700

ReferenceRanges

-LowHighText
*7 U/L (Details: UCUM codeU/L = 'U/L')56 U/L (Details: UCUM codeU/L = 'U/L')

7 – 56 U/L


Entry 15 - fullUrl = http://fhir.hl7.org.vn/core/DiagnosticReport/InlineDiagnosticReportCBCBiochem

Resource DiagnosticReport:

Xét nghiệm máu tổng quát — CBC + Sinh hoá cơ bản (Xét nghiệm)

SubjectNguyễn Văn An Male, DoB: 1985-03-15 ( Căn cước công dân: VNCCCD#001085012345)
Relevant Time2026-04-15 09:00:00+0700
Reported2026-04-15 10:30:00+0700
Performer Bệnh viện Chợ Rẫy

Report Details

CodeValueReference RangeFlagsNote
Bạch cầu (WBC)15.2 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')4.0 – 10.0 ×10⁹/LFinal, Cao

Tăng bạch cầu (leukocytosis): WBC 15.2 × 10⁹/L. Gợi ý nhiễm trùng vi khuẩn cấp. Đề nghị CRP để đánh giá mức độ viêm.

Hồng cầu (RBC)4.8 ×10¹²/L (Details: UCUM code10*12/L = '10*12/L')4.0 – 5.5 ×10¹²/L (nam)Final
Hemoglobin (Hgb)145 g/L (Details: UCUM codeg/L = 'g/L')130 – 170 g/L (nam)Final
Tiểu cầu (PLT)250 ×10⁹/L (Details: UCUM code10*9/L = '10*9/L')150 – 400 ×10⁹/LFinal
Glucose máu lúc đói5.4 mmol/L (Details: UCUM codemmol/L = 'mmol/L')3.9 – 6.1 mmol/LFinal
Creatinine huyết thanh85 µmol/L (Details: UCUM codeumol/L = 'umol/L')62 – 106 µmol/L (nam)Final
ALT (SGPT)32 U/L (Details: UCUM codeU/L = 'U/L')7 – 56 U/LFinal

TĂNG BẠCH CẦU: WBC 15.2 ×10⁹/L (bình thường: 4.0–10.0). Gợi ý nhiễm trùng vi khuẩn cấp. Cần CRP và công thức bạch cầu để xác định loại nhiễm trùng. Các chỉ số còn lại (RBC, Hgb, PLT, Glucose, Creatinine, ALT) trong giới hạn bình thường — loại trừ thiếu máu, Dengue, suy thận, viêm gan cấp.

Coded Conclusions:

  • Tăng bạch cầu không đặc hiệu — gợi ý nhiễm trùng vi khuẩn

Entry 16 - fullUrl = http://fhir.hl7.org.vn/core/ServiceRequest/InlineServiceRequestCRP

Resource ServiceRequest:

status: Active

intent: Order

category: Xét nghiệm

priority: Urgent

code: No display for ServiceRequest.code (concept: C reactive protein [Mass/volume] in Serum or Plasma)

subject: Nguyễn Văn An

encounter: Encounter: identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-15-0318; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-15 08:00:00+0700 --> 2026-04-15 11:30:00+0700

authoredOn: 2026-04-15 11:00:00+0700

requester: BS CKII Nguyễn Thị Lan

performer: Bệnh viện Chợ Rẫy

specimen: Mẫu huyết thanh xét nghiệm sinh hoá

note:

Chỉ định bổ sung sau kết quả CBC: WBC = 15.2 × 10⁹/L (cao). Dùng cùng mẫu máu đã lấy lúc 09:00. Kết quả ưu tiên — trả trong 2 giờ.