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

• Nội dung narrative
• XML
• JSON
• TTL

: Ví dụ — Bệnh án ngoại trú (tăng huyết áp)

Bản thô ttl | Tải xuống

@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "ExampleCompositionEMR"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition"^^xsd:anyURI ;
fhir:l <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition>     ] )
  ] ; # 
  fhir:language [ fhir:v "vi"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"vi\" lang=\"vi\"><p class=\"res-header-id\"><b>Generated Narrative: Composition ExampleCompositionEMR</b></p><a name=\"ExampleCompositionEMR\"> </a><a name=\"hcExampleCompositionEMR\"> </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\">Language: vi</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-vn-core-composition.html\">Bệnh án điện tử VN Core — VN Core Composition Profile</a></p></div><p><b>identifier</b>: <a href=\"NamingSystem-vn-document-number-ns.html\" title=\"Namespace khuyến nghị cho mã tài liệu lâm sàng nội bộ do cơ sở y tế phát sinh, dùng cho Composition.identifier và DocumentReference.identifier khi chưa có NamingSystem riêng của từng cơ sở.\">VNDocumentNumber</a>/BA-2026-00451</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 34108-1}\">Outpatient Note</span></p><p><b>encounter</b>: <a href=\"Encounter-ExampleEncounterOutpatient.html\">Encounter: extension = Khám chữa bệnh ban đầu; status = finished; class = ambulatory (ActCode#AMB); period = 2026-03-19 08:30:00+0700 --&gt; 2026-03-19 11:00:00+0700; reasonCode = </a></p><p><b>date</b>: 2026-03-22 09:30:00+0700</p><p><b>author</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">Practitioner Nguyễn Thị Lan</a></p><p><b>title</b>: Bệnh án ngoại trú</p><p><b>confidentiality</b>: restricted</p><p><b>custodian</b>: <a href=\"Organization-ExampleOrganizationChoRay.html\">Organization Bệnh viện Chợ Rẫy</a></p></div>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier [
fhir:system [
fhir:v "http://fhir.hl7.org.vn/core/sid/document-number"^^xsd:anyURI ;
fhir:l <http://fhir.hl7.org.vn/core/sid/document-number>     ] ;
fhir:value [ fhir:v "BA-2026-00451" ]
  ] ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:type [
    ( fhir:coding [
a loinc:34108-1 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>       ] ;
fhir:code [ fhir:v "34108-1" ] ;
fhir:display [ fhir:v "Outpatient Note" ]     ] )
  ] ; # 
  fhir:subject [
fhir:l fhir:Patient/ExamplePatientNguyenVanAn ;
fhir:reference [ fhir:v "Patient/ExamplePatientNguyenVanAn" ]
  ] ; # 
  fhir:encounter [
fhir:l fhir:Encounter/ExampleEncounterOutpatient ;
fhir:reference [ fhir:v "Encounter/ExampleEncounterOutpatient" ]
  ] ; # 
  fhir:date [ fhir:v "2026-03-22T09:30:00+07:00"^^xsd:dateTime] ; # 
  fhir:author ( [
fhir:l fhir:Practitioner/ExamplePractitionerBSCKII ;
fhir:reference [ fhir:v "Practitioner/ExamplePractitionerBSCKII" ]
  ] ) ; # 
  fhir:title [ fhir:v "Bệnh án ngoại trú"] ; # 
  fhir:confidentiality [ fhir:v "R"] ; # 
  fhir:custodian [
fhir:l fhir:Organization/ExampleOrganizationChoRay ;
fhir:reference [ fhir:v "Organization/ExampleOrganizationChoRay" ]
  ] ; # 
  fhir:section ( [
fhir:title [ fhir:v "Lý do đến khám" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10154-3 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>         ] ;
fhir:code [ fhir:v "10154-3" ] ;
fhir:display [ fhir:v "Chief complaint Narrative - Reported" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\">Đau đầu, chóng mặt kéo dài 2 tuần. Tiền sử tăng huyết áp chưa điều trị.</div>"^^rdf:XMLLiteral ]     ]
  ] [
fhir:title [ fhir:v "Chẩn đoán" ] ;
fhir:code [
      ( fhir:coding [
a loinc:29548-5 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>         ] ;
fhir:code [ fhir:v "29548-5" ] ;
fhir:display [ fhir:v "Diagnosis Narrative" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\">Tăng huyết áp nguyên phát, độ II (I10 — ICD-10 VN per QĐ 4469/QĐ-BYT).</div>"^^rdf:XMLLiteral ]     ]
  ] [
fhir:title [ fhir:v "Thuốc điều trị" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10160-0 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>         ] ;
fhir:code [ fhir:v "10160-0" ] ;
fhir:display [ fhir:v "History of Medication use Narrative" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\">Amlodipine 5mg x 1 viên/ngày, uống sáng. Tái khám sau 2 tuần.</div>"^^rdf:XMLLiteral ]     ]
  ] ) . #