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 xml | Tải xuống

<Composition xmlns="http://hl7.org/fhir">
  <id value="ExampleCompositionEMR"/>
  <meta>
    <profile
             value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition"/>
  </meta>
  <language value="vi"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <identifier>
    <system value="http://fhir.hl7.org.vn/core/sid/document-number"/>
    <value value="BA-2026-00451"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="34108-1"/>
      <display value="Outpatient Note"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/ExamplePatientNguyenVanAn"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/ExampleEncounterOutpatient"/>
  </encounter>
  <date value="2026-03-22T09:30:00+07:00"/>
  <author>🔗 
    <reference value="Practitioner/ExamplePractitionerBSCKII"/>
  </author>
  <title value="Bệnh án ngoại trú"/>
  <confidentiality value="R"/>
  <custodian>🔗 
    <reference value="Organization/ExampleOrganizationChoRay"/>
  </custodian>
  <section>
    <title value="Lý do đến khám"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10154-3"/>
        <display value="Chief complaint Narrative - Reported"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
  <section>
    <title value="Chẩn đoán"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29548-5"/>
        <display value="Diagnosis Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
  <section>
    <title value="Thuốc điều trị"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="History of Medication use Narrative"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Amlodipine 5mg x 1 viên/ngày, uống sáng. Tái khám sau 2 tuần.</div>
    </text>
  </section>
</Composition>