Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.3.0 - STU1 Draft
Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="ExampleBundleReferralUpward"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-bundle"/>
</meta>
<language value="vi"/>
<type value="collection"/>
<timestamp value="2026-04-08T15:00:00+07:00"/>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Patient/InlinePatientTranThiMai"/>
<resource>
<Patient>
<id value="InlinePatientTranThiMai"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient"/>
</meta>
<language value="vi"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_InlinePatientTranThiMai"> </a><p class="res-header-id"><b>Generated Narrative: Patient InlinePatientTranThiMai</b></p><a name="InlinePatientTranThiMai"> </a><a name="hcInlinePatientTranThiMai"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-patient.html">Bệnh nhân VN Core — VN Core Patient Profile</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Trần Thị Mai Female, DoB: 1964-08-20 ( Căn cước công dân: VNCCCD#075162034567)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Other Ids (see the one above)">Other Ids:</td><td colspan="3">Thẻ bảo hiểm y tế/075162034567</td></tr><tr><td style="background-color: #f3f5da" title="Ways to contact the Patient">Contact Detail</td><td colspan="3">Xã Tân Phú, Đồng Nai</td></tr><tr><td style="background-color: #f3f5da" title="Mở rộng ghi nhận dân tộc của bệnh nhân theo danh mục 54 dân tộc Việt Nam
(Tổng cục Thống kê). FHIR base chỉ có US Race/Ethnicity — không phù hợp cho Việt Nam.
Căn cứ: Hiến pháp 2013 Điều 5, Luật Căn cước 2023."><a href="StructureDefinition-vn-ext-ethnicity.html">Dân tộc — Vietnam Ethnicity Extension</a></td><td colspan="3"><span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-ethnicity-cs 01}">Kinh</span></td></tr></table></div>
</text>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-ethnicity">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-ethnicity-cs"/>
<code value="01"/>
<display value="Kinh"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs"/>
<code value="CCCD"/>
<display value="Căn cước công dân"/>
</coding>
</type>
<system value="http://fhir.hl7.org.vn/core/sid/cccd"/>
<value value="075162034567"/>
</identifier>
<identifier>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs"/>
<code value="BHYT"/>
<display value="Thẻ bảo hiểm y tế"/>
</coding>
</type>
<system value="http://fhir.hl7.org.vn/core/sid/bhyt"/>
<value value="075162034567"/>
</identifier>
<name>
<text value="Trần Thị Mai"/>
<family value="Trần"/>
<given value="Thị Mai"/>
</name>
<gender value="female"/>
<birthDate value="1964-08-20"/>
<address>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-province">
<valueCoding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-province-cs"/>
<code value="75"/>
<display value="Tỉnh Đồng Nai"/>
</valueCoding>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-ward">
<valueCoding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-ward-cs"/>
<code value="26116"/>
<display value="Xã Tân Phú"/>
</valueCoding>
</extension>
<text value="Xã Tân Phú, Đồng Nai"/>
<state value="Đồng Nai"/>
<country value="VN"/>
</address>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Organization/ExampleOrganizationTramYTe"/>
<resource>
<Organization>
<id value="ExampleOrganizationTramYTe"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization"/>
</meta>
<language value="vi"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_ExampleOrganizationTramYTe"> </a><p class="res-header-id"><b>Generated Narrative: Organization ExampleOrganizationTramYTe</b></p><a name="ExampleOrganizationTramYTe"> </a><a name="hcExampleOrganizationTramYTe"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-organization.html">Cơ sở y tế VN Core — VN Core Organization Profile</a></p></div><p><b>Loại hình cơ sở y tế — Vietnam Organization Type Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-type-cs TYT}">Trạm y tế</span></p><p><b>Cấp quản lý hành chính y tế — Vietnam Administrative Health Level Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-healthcare-level-cs XA}">Xã</span></p><p><b>Tình trạng xếp hạng cơ sở y tế — Organization Rank Status Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-rank-status-cs NOT_APPLICABLE}">Không áp dụng</span></p><p><b>Cấp năng lực cơ sở KCB — Facility Care Level Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-facility-care-level-cs BAN_DAU}">Cấp ban đầu</span></p><p><b>identifier</b>: Mã cơ sở khám chữa bệnh/01500</p><p><b>active</b>: true</p><p><b>name</b>: Trạm Y tế phường Ngọc Hà</p><p><b>address</b>: Phường Ngọc Hà, Thành phố Hà Nội</p></div>
</text>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-type">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-type-cs"/>
<code value="TYT"/>
<display value="Trạm y tế"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-level">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-healthcare-level-cs"/>
<code value="XA"/>
<display value="Xã"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-rank-status">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-rank-status-cs"/>
<code value="NOT_APPLICABLE"/>
<display value="Không áp dụng"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-facility-care-level">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-facility-care-level-cs"/>
<code value="BAN_DAU"/>
<display value="Cấp ban đầu"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs"/>
<code value="CSKCB"/>
<display value="Mã cơ sở khám chữa bệnh"/>
</coding>
</type>
<system value="http://fhir.hl7.org.vn/core/sid/ma-cskcb"/>
<value value="01500"/>
</identifier>
<active value="true"/>
<name value="Trạm Y tế phường Ngọc Hà"/>
<address>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-province">
<valueCoding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-province-cs"/>
<code value="01"/>
<display value="Thành phố Hà Nội"/>
</valueCoding>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-ward">
<valueCoding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-ward-cs"/>
<code value="00008"/>
<display value="Phường Ngọc Hà"/>
</valueCoding>
</extension>
<text value="Phường Ngọc Hà, Thành phố Hà Nội"/>
<state value="Thành phố Hà Nội"/>
<country value="VN"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Organization/InlineOrganizationBVTinhDongNai"/>
<resource>
<Organization>
<id value="InlineOrganizationBVTinhDongNai"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization"/>
</meta>
<language value="vi"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_InlineOrganizationBVTinhDongNai"> </a><p class="res-header-id"><b>Generated Narrative: Organization InlineOrganizationBVTinhDongNai</b></p><a name="InlineOrganizationBVTinhDongNai"> </a><a name="hcInlineOrganizationBVTinhDongNai"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-organization.html">Cơ sở y tế VN Core — VN Core Organization Profile</a></p></div><p><b>Loại hình cơ sở y tế — Vietnam Organization Type Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-type-cs BV}">Bệnh viện</span></p><p><b>Cấp quản lý hành chính y tế — Vietnam Administrative Health Level Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-healthcare-level-cs TINH}">Tỉnh</span></p><p><b>Hạng cơ sở khám bệnh, chữa bệnh — Vietnam KCB Facility Rank Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-hospital-rank-cs I}">Hạng I</span></p><p><b>Tình trạng xếp hạng cơ sở y tế — Organization Rank Status Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-rank-status-cs RANKED}">Đã xếp hạng</span></p><p><b>Cấp năng lực cơ sở KCB — Facility Care Level Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-facility-care-level-cs CO_BAN}">Cấp cơ bản</span></p><p><b>identifier</b>: Mã cơ sở khám chữa bệnh/75001</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span></p><p><b>name</b>: Bệnh viện Đa khoa Đồng Nai</p></div>
</text>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-type">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-type-cs"/>
<code value="BV"/>
<display value="Bệnh viện"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-level">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-healthcare-level-cs"/>
<code value="TINH"/>
<display value="Tỉnh"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-rank">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-hospital-rank-cs"/>
<code value="I"/>
<display value="Hạng I"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-org-rank-status">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-organization-rank-status-cs"/>
<code value="RANKED"/>
<display value="Đã xếp hạng"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-facility-care-level">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-facility-care-level-cs"/>
<code value="CO_BAN"/>
<display value="Cấp cơ bản"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs"/>
<code value="CSKCB"/>
<display value="Mã cơ sở khám chữa bệnh"/>
</coding>
</type>
<system value="http://fhir.hl7.org.vn/core/sid/ma-cskcb"/>
<value value="75001"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Bệnh viện Đa khoa Đồng Nai"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa"/>
<resource>
<Encounter>
<id value="InlineEncounterPrimaryXa"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter"/>
</meta>
<language value="vi"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Encounter_InlineEncounterPrimaryXa"> </a><p class="res-header-id"><b>Generated Narrative: Encounter InlineEncounterPrimaryXa</b></p><a name="InlineEncounterPrimaryXa"> </a><a name="hcInlineEncounterPrimaryXa"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-encounter.html">Lượt khám/nhập viện VN Core — VN Core Encounter Profile</a></p></div><p><b>Loại khám chữa bệnh BHYT — Vietnam Insurance Visit Type Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-insurance-visit-type-cs 5}">Khám chữa bệnh ban đầu</span></p><p><b>Hình thức chuyển tuyến — Referral Mode Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-referral-mode-cs 2}">Chuyển đến từ tuyến dưới</span></p><p><b>Kết quả điều trị — Vietnam Treatment Outcome Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-treatment-outcome-cs 7}">Chưa xác định</span></p><p><b>Mã lượt khám — Encounter Code Extension</b>: Mã lượt khám chữa bệnh/LK-TYT-2026-04-08-001</p><p><b>status</b>: Finished</p><p><b>class</b>: <a href="http://terminology.hl7.org/7.1.0/CodeSystem-v3-ActCode.html#v3-ActCode-AMB">ActCode: AMB</a> (ambulatory)</p><p><b>type</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-encounter-type-cs 01}">Khám cấp cứu tại trạm y tế xã</span></p><p><b>subject</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Patient_InlinePatientTranThiMai">Trần Thị Mai</a></p><p><b>period</b>: 2026-04-08 14:00:00+0700 --> 2026-04-08 14:45:00+0700</p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Condition</b></td><td><b>Use</b></td></tr><tr><td style="display: none">*</td><td><a href="Bundle-ExampleBundleReferralUpward.html#Condition_InlineConditionSuspectedMI">I21.9 — Nhồi máu cơ tim cấp (nghi ngờ)</a></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/diagnosis-role AD}">Admission diagnosis</span></td></tr></table><p><b>serviceProvider</b>: <a href="Organization-ExampleOrganizationTramYTe.html">Trạm Y tế xã Tân Phú</a></p></div>
</text>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-visit-type">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-insurance-visit-type-cs"/>
<code value="5"/>
<display value="Khám chữa bệnh ban đầu"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-referral-mode">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-referral-mode-cs"/>
<code value="2"/>
<display value="Chuyển đến từ tuyến dưới"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-treatment-outcome">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-treatment-outcome-cs"/>
<code value="7"/>
<display value="Chưa xác định"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-encounter-code">
<valueIdentifier>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs"/>
<code value="MA_LUOT_KCB"/>
<display value="Mã lượt khám chữa bệnh"/>
</coding>
</type>
<system value="http://fhir.hl7.org.vn/core/sid/ma-luot-kcb"/>
<value value="LK-TYT-2026-04-08-001"/>
</valueIdentifier>
</extension>
<status value="finished"/>
<class>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="AMB"/>
<display value="ambulatory"/>
</class>
<type>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-encounter-type-cs"/>
<code value="01"/>
<display value="Khám bệnh"/>
</coding>
<text value="Khám cấp cứu tại trạm y tế xã"/>
</type>
<subject>
<reference value="Patient/InlinePatientTranThiMai"/>
<display value="Trần Thị Mai"/>
</subject>
<period>
<start value="2026-04-08T14:00:00+07:00"/>
<end value="2026-04-08T14:45:00+07:00"/>
</period>
<diagnosis>
<condition>
<reference value="Condition/InlineConditionSuspectedMI"/>
<display value="I21.9 — Nhồi máu cơ tim cấp (nghi ngờ)"/>
</condition>
<use>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/diagnosis-role"/>
<code value="AD"/>
<display value="Admission diagnosis"/>
</coding>
</use>
</diagnosis>
<serviceProvider>🔗
<reference value="Organization/ExampleOrganizationTramYTe"/>
<display value="Trạm Y tế xã Tân Phú"/>
</serviceProvider>
</Encounter>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Condition/InlineConditionSuspectedMI"/>
<resource>
<Condition>
<id value="InlineConditionSuspectedMI"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-condition"/>
</meta>
<language value="vi"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Condition_InlineConditionSuspectedMI"> </a><p class="res-header-id"><b>Generated Narrative: Condition InlineConditionSuspectedMI</b></p><a name="InlineConditionSuspectedMI"> </a><a name="hcInlineConditionSuspectedMI"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-condition.html">Chẩn đoán VN Core — VN Core Condition Profile</a></p></div><p><b>clinicalStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}">Active</span></p><p><b>verificationStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-ver-status provisional}">Provisional</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}">Encounter Diagnosis</span></p><p><b>code</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10 I21.9}">Nhồi máu cơ tim cấp, không đặc hiệu (chẩn đoán sơ bộ)</span></p><p><b>subject</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Patient_InlinePatientTranThiMai">Trần Thị Mai</a></p><p><b>encounter</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Encounter_InlineEncounterPrimaryXa">Encounter: extension = Khám chữa bệnh ban đầu,Chuyển đến từ tuyến dưới,Chưa xác định,Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-TYT-2026-04-08-001; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-08 14:00:00+0700 --> 2026-04-08 14:45:00+0700</a></p><p><b>onset</b>: 2026-04-08 13:30:00+0700</p><p><b>recordedDate</b>: 2026-04-08</p><p><b>note</b>: </p><blockquote><div><p>Đau ngực trái đột ngột lan ra cánh tay trái, vã mồ hôi, khó thở. Tiền sử tăng huyết áp không kiểm soát. ECG tại trạm y tế: ST chênh lên ở DII, DIII, aVF. Nghi STEMI thành dưới.</p>
</div></blockquote></div>
</text>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
<display value="Active"/>
</coding>
</clinicalStatus>
<verificationStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
<code value="provisional"/>
<display value="Provisional"/>
</coding>
</verificationStatus>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-category"/>
<code value="encounter-diagnosis"/>
<display value="Encounter Diagnosis"/>
</coding>
</category>
<code>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10"/>
<code value="I21.9"/>
<display value="Acute myocardial infarction, unspecified"/>
</coding>
<text
value="Nhồi máu cơ tim cấp, không đặc hiệu (chẩn đoán sơ bộ)"/>
</code>
<subject>
<reference value="Patient/InlinePatientTranThiMai"/>
<display value="Trần Thị Mai"/>
</subject>
<encounter>
<reference value="Encounter/InlineEncounterPrimaryXa"/>
</encounter>
<onsetDateTime value="2026-04-08T13:30:00+07:00"/>
<recordedDate value="2026-04-08"/>
<note>
<text
value="Đau ngực trái đột ngột lan ra cánh tay trái, vã mồ hôi, khó thở. Tiền sử tăng huyết áp không kiểm soát. ECG tại trạm y tế: ST chênh lên ở DII, DIII, aVF. Nghi STEMI thành dưới."/>
</note>
</Condition>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/Observation/InlineObservationECGAbnormal"/>
<resource>
<Observation>
<id value="InlineObservationECGAbnormal"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab"/>
</meta>
<language value="vi"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_InlineObservationECGAbnormal"> </a><p class="res-header-id"><b>Generated Narrative: Observation InlineObservationECGAbnormal</b></p><a name="InlineObservationECGAbnormal"> </a><a name="hcInlineObservationECGAbnormal"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-observation-lab.html">Xét nghiệm VN Core — VN Core Observation Laboratory Profile</a></p></div><p><b>status</b>: Preliminary</p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span></p><p><b>code</b>: <span title="Codes:{http://loinc.org 11524-6}">Điện tâm đồ (ECG)</span></p><p><b>subject</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Patient_InlinePatientTranThiMai">Trần Thị Mai</a></p><p><b>encounter</b>: <a href="Bundle-ExampleBundleReferralUpward.html#http-//fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa">Khám ban đầu tại Trạm Y tế xã Tân Phú</a></p><p><b>effective</b>: 2026-04-08 14:15:00+0700</p><p><b>performer</b>: <a href="Organization-ExampleOrganizationTramYTe.html">Trạm Y tế xã Tân Phú</a></p><p><b>value</b>: Nhịp xoang 92 lần/phút. ST chênh lên 3mm ở DII, DIII, aVF. Nghi STEMI thành dưới.</p><p><b>interpretation</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation A}">Bất thường — nghi ngờ nhồi máu cơ tim cấp</span></p></div>
</text>
<status value="preliminary"/>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/observation-category"/>
<code value="laboratory"/>
<display value="Laboratory"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11524-6"/>
<display value="EKG study"/>
</coding>
<text value="Điện tâm đồ (ECG)"/>
</code>
<subject>
<reference value="Patient/InlinePatientTranThiMai"/>
<display value="Trần Thị Mai"/>
</subject>
<encounter>
<reference
value="http://fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa"/>
<display value="Khám ban đầu tại Trạm Y tế xã Tân Phú"/>
</encounter>
<effectiveDateTime value="2026-04-08T14:15:00+07:00"/>
<performer>🔗
<reference value="Organization/ExampleOrganizationTramYTe"/>
<display value="Trạm Y tế xã Tân Phú"/>
</performer>
<valueString
value="Nhịp xoang 92 lần/phút. ST chênh lên 3mm ở DII, DIII, aVF. Nghi STEMI thành dưới."/>
<interpretation>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
<code value="A"/>
<display value="Abnormal"/>
</coding>
<text value="Bất thường — nghi ngờ nhồi máu cơ tim cấp"/>
</interpretation>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/ServiceRequest/InlineServiceRequestReferralUpward"/>
<resource>
<ServiceRequest>
<id value="InlineServiceRequestReferralUpward"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-service-request"/>
</meta>
<language value="vi"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ServiceRequest_InlineServiceRequestReferralUpward"> </a><p class="res-header-id"><b>Generated Narrative: ServiceRequest InlineServiceRequestReferralUpward</b></p><a name="InlineServiceRequestReferralUpward"> </a><a name="hcInlineServiceRequestReferralUpward"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-service-request.html">Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile</a></p></div><p><b>Hình thức chuyển tuyến — Referral Mode Extension</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-referral-mode-cs 2}">Chuyển đến từ tuyến dưới</span></p><p><b>status</b>: Active</p><p><b>intent</b>: Order</p><p><b>category</b>: <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs KHAM}">Khám chuyên khoa</span></p><p><b>priority</b>: Urgent</p><p><b>code</b>: <span title="Codes:">Chuyển tuyến cấp cứu — nghi nhồi máu cơ tim cấp I21.9</span></p><p><b>subject</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Patient_InlinePatientTranThiMai">Trần Thị Mai</a></p><p><b>encounter</b>: <a href="Bundle-ExampleBundleReferralUpward.html#http-//fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa">Encounter: extension = Khám chữa bệnh ban đầu,Chuyển đến từ tuyến dưới,Chưa xác định,Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-TYT-2026-04-08-001; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-04-08 14:00:00+0700 --> 2026-04-08 14:45:00+0700</a></p><p><b>authoredOn</b>: 2026-04-08 14:30:00+0700</p><p><b>requester</b>: <a href="Organization-ExampleOrganizationTramYTe.html">Trạm Y tế xã Tân Phú</a></p><p><b>performer</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Organization_InlineOrganizationBVTinhDongNai">Bệnh viện Đa khoa Đồng Nai</a></p><p><b>reasonCode</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10 I21.9}">Nghi nhồi máu cơ tim cấp — cần PCI cấp cứu, vượt quá khả năng trạm y tế</span></p><p><b>note</b>: </p><blockquote><div><p>Chuyển tuyến LÊN (xã → tỉnh). Đã sơ cứu: Aspirin 300mg nhai, NTG 0.5mg ngậm dưới lưỡi × 1 lần. HA 100/60 mmHg. Chuyển cấp cứu bằng xe cứu thương.</p>
</div></blockquote></div>
</text>
<extension
url="http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-referral-mode">
<valueCodeableConcept>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-referral-mode-cs"/>
<code value="2"/>
<display value="Chuyển đến từ tuyến dưới"/>
</coding>
</valueCodeableConcept>
</extension>
<status value="active"/>
<intent value="order"/>
<category>
<coding>
<system
value="http://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs"/>
<code value="KHAM"/>
<display value="Khám chuyên khoa"/>
</coding>
</category>
<priority value="urgent"/>
<code>
<text
value="Chuyển tuyến cấp cứu — nghi nhồi máu cơ tim cấp I21.9"/>
</code>
<subject>
<reference value="Patient/InlinePatientTranThiMai"/>
<display value="Trần Thị Mai"/>
</subject>
<encounter>
<reference
value="http://fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa"/>
</encounter>
<authoredOn value="2026-04-08T14:30:00+07:00"/>
<requester>🔗
<reference value="Organization/ExampleOrganizationTramYTe"/>
<display value="Trạm Y tế xã Tân Phú"/>
</requester>
<performer>
<reference value="Organization/InlineOrganizationBVTinhDongNai"/>
<display value="Bệnh viện Đa khoa Đồng Nai"/>
</performer>
<reasonCode>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10"/>
<code value="I21.9"/>
<display value="Acute myocardial infarction, unspecified"/>
</coding>
<text
value="Nghi nhồi máu cơ tim cấp — cần PCI cấp cứu, vượt quá khả năng trạm y tế"/>
</reasonCode>
<note>
<text
value="Chuyển tuyến LÊN (xã → tỉnh). Đã sơ cứu: Aspirin 300mg nhai, NTG 0.5mg ngậm dưới lưỡi × 1 lần. HA 100/60 mmHg. Chuyển cấp cứu bằng xe cứu thương."/>
</note>
</ServiceRequest>
</resource>
</entry>
<entry>
<fullUrl
value="http://fhir.hl7.org.vn/core/DocumentReference/InlineDocumentReferenceReferralLetter"/>
<resource>
<DocumentReference>
<id value="InlineDocumentReferenceReferralLetter"/>
<meta>
<profile
value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-document-reference"/>
</meta>
<language value="vi"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="DocumentReference_InlineDocumentReferenceReferralLetter"> </a><p class="res-header-id"><b>Generated Narrative: DocumentReference InlineDocumentReferenceReferralLetter</b></p><a name="InlineDocumentReferenceReferralLetter"> </a><a name="hcInlineDocumentReferenceReferralLetter"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-document-reference.html">Tài liệu y tế VN Core — VN Core DocumentReference Profile</a></p></div><p><b>status</b>: Current</p><p><b>type</b>: <span title="Codes:{http://loinc.org 57133-1}">Giấy chuyển viện</span></p><p><b>subject</b>: <a href="Bundle-ExampleBundleReferralUpward.html#Patient_InlinePatientTranThiMai">Trần Thị Mai</a></p><p><b>date</b>: 2026-04-08 14:35:00+0700</p><p><b>author</b>: <a href="Organization-ExampleOrganizationTramYTe.html">Trạm Y tế xã Tân Phú</a></p><p><b>description</b>: Giấy chuyển viện — chuyển tuyến lên BV Đa khoa Đồng Nai. Lý do: nghi nhồi máu cơ tim cấp, cần can thiệp mạch vành.</p><blockquote><p><b>content</b></p><h3>Attachments</h3><table class="grid"><tr><td style="display: none">-</td><td><b>ContentType</b></td><td><b>Title</b></td><td><b>Creation</b></td></tr><tr><td style="display: none">*</td><td>application/pdf</td><td>Giay-chuyen-vien-TranThiMai-20260408.pdf</td><td>2026-04-08 14:35:00+0700</td></tr></table></blockquote><h3>Contexts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Encounter</b></td></tr><tr><td style="display: none">*</td><td><a href="Bundle-ExampleBundleReferralUpward.html#http-//fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa">Khám ban đầu tại Trạm Y tế xã Tân Phú</a></td></tr></table></div>
</text>
<status value="current"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="57133-1"/>
<display value="Referral note"/>
</coding>
<text value="Giấy chuyển viện"/>
</type>
<subject>
<reference value="Patient/InlinePatientTranThiMai"/>
<display value="Trần Thị Mai"/>
</subject>
<date value="2026-04-08T14:35:00+07:00"/>
<author>🔗
<reference value="Organization/ExampleOrganizationTramYTe"/>
<display value="Trạm Y tế xã Tân Phú"/>
</author>
<description
value="Giấy chuyển viện — chuyển tuyến lên BV Đa khoa Đồng Nai. Lý do: nghi nhồi máu cơ tim cấp, cần can thiệp mạch vành."/>
<content>
<attachment>
<contentType value="application/pdf"/>
<title value="Giay-chuyen-vien-TranThiMai-20260408.pdf"/>
<creation value="2026-04-08T14:35:00+07:00"/>
</attachment>
</content>
<context>
<encounter>
<reference
value="http://fhir.hl7.org.vn/core/Encounter/InlineEncounterPrimaryXa"/>
<display value="Khám ban đầu tại Trạm Y tế xã Tân Phú"/>
</encounter>
</context>
</DocumentReference>
</resource>
</entry>
</Bundle>