HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.3.0 - STU1 Draft Viet Nam cờ

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

: Ví dụ: Công thức máu toàn phần (CBC)

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{
  "resourceType" : "Observation",
  "id" : "ExampleObservationLabCBC",
  "meta" : {
    "profile" : [
      🔗 "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab"
    ]
  },
  "language" : "vi",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"vi\" lang=\"vi\"><p class=\"res-header-id\"><b>Generated Narrative: Observation ExampleObservationLabCBC</b></p><a name=\"ExampleObservationLabCBC\"> </a><a name=\"hcExampleObservationLabCBC\"> </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-observation-lab.html\">Xét nghiệm VN Core — VN Core Observation Laboratory Profile</a></p></div><p><b>status</b>: Final</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 58410-2}\">Công thức máu (CBC)</span></p><p><b>subject</b>: <a href=\"Patient-ExamplePatientNguyenVanAn.html\">Nguyễn Văn An</a></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>effective</b>: 2026-04-20 07:45:00+0700</p><p><b>performer</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">BS CKII Nguyễn Thị Lan</a></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation A}\">Abnormal</span></p><p><b>note</b>: </p><blockquote><div><p>WBC 12.8 × 10⁹/L — tăng cao (ref: 4.0–10.0). Nghi ngờ nhiễm trùng cấp tính. Cần theo dõi lâm sàng, cân nhắc cấy máu nếu sốt &gt; 38.5°C. Các chỉ số huyết học khác trong giới hạn bình thường.</p>\n</div></blockquote><p><b>specimen</b>: <a href=\"Specimen-ExampleSpecimenWholeBloodCBC.html\">Mẫu máu toàn phần chống đông EDTA</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 6690-2}\">Bạch cầu (WBC)</span></p><p><b>value</b>: 12.8 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>4 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></td><td>10 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></td><td>4.0 – 10.0 × 10⁹/L</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 789-8}\">Hồng cầu (RBC)</span></p><p><b>value</b>: 4.6 10^12/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*12/L = '10*12/L')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}\">Normal</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>4 10^12/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*12/L = '10*12/L')</span></td><td>5.5 10^12/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*12/L = '10*12/L')</span></td><td>4.0 – 5.5 × 10¹²/L (nam)</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 718-7}\">Hemoglobin (Hgb)</span></p><p><b>value</b>: 138 g/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/L = 'g/L')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}\">Normal</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>130 g/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/L = 'g/L')</span></td><td>170 g/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/L = 'g/L')</span></td><td>130 – 170 g/L (nam)</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 777-3}\">Tiểu cầu (PLT)</span></p><p><b>value</b>: 220 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}\">Normal</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>150 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></td><td>400 10^9/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*9/L = '10*9/L')</span></td><td>150 – 400 × 10⁹/L</td></tr></table></blockquote></div>"
  },
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
          "code" : "laboratory",
          "display" : "Laboratory"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "58410-2",
        "display" : "CBC panel - Blood by Automated count"
      }
    ],
    "text" : "Công thức máu (CBC)"
  },
  "subject" : {
    🔗 "reference" : "Patient/ExamplePatientNguyenVanAn",
    "display" : "Nguyễn Văn An"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/ExampleEncounterOutpatient"
  },
  "effectiveDateTime" : "2026-04-20T07:45:00+07:00",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/ExamplePractitionerBSCKII",
      "display" : "BS CKII Nguyễn Thị Lan"
    }
  ],
  "interpretation" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
          "code" : "A",
          "display" : "Abnormal"
        }
      ]
    }
  ],
  "note" : [
    {
      "text" : "WBC 12.8 × 10⁹/L — tăng cao (ref: 4.0–10.0). Nghi ngờ nhiễm trùng cấp tính. Cần theo dõi lâm sàng, cân nhắc cấy máu nếu sốt > 38.5°C. Các chỉ số huyết học khác trong giới hạn bình thường."
    }
  ],
  "specimen" : {
    🔗 "reference" : "Specimen/ExampleSpecimenWholeBloodCBC",
    "display" : "Mẫu máu toàn phần chống đông EDTA"
  },
  "component" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "6690-2",
            "display" : "Leukocytes [#/volume] in Blood by Automated count"
          }
        ],
        "text" : "Bạch cầu (WBC)"
      },
      "valueQuantity" : {
        "value" : 12.8,
        "unit" : "10^9/L",
        "system" : "http://unitsofmeasure.org",
        "code" : "10*9/L"
      },
      "interpretation" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
              "code" : "H",
              "display" : "High"
            }
          ]
        }
      ],
      "referenceRange" : [
        {
          "low" : {
            "value" : 4,
            "unit" : "10^9/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*9/L"
          },
          "high" : {
            "value" : 10,
            "unit" : "10^9/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*9/L"
          },
          "text" : "4.0 – 10.0 × 10⁹/L"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "789-8",
            "display" : "Erythrocytes [#/volume] in Blood by Automated count"
          }
        ],
        "text" : "Hồng cầu (RBC)"
      },
      "valueQuantity" : {
        "value" : 4.6,
        "unit" : "10^12/L",
        "system" : "http://unitsofmeasure.org",
        "code" : "10*12/L"
      },
      "interpretation" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
              "code" : "N",
              "display" : "Normal"
            }
          ]
        }
      ],
      "referenceRange" : [
        {
          "low" : {
            "value" : 4,
            "unit" : "10^12/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*12/L"
          },
          "high" : {
            "value" : 5.5,
            "unit" : "10^12/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*12/L"
          },
          "text" : "4.0 – 5.5 × 10¹²/L (nam)"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "718-7",
            "display" : "Hemoglobin [Mass/volume] in Blood"
          }
        ],
        "text" : "Hemoglobin (Hgb)"
      },
      "valueQuantity" : {
        "value" : 138,
        "unit" : "g/L",
        "system" : "http://unitsofmeasure.org",
        "code" : "g/L"
      },
      "interpretation" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
              "code" : "N",
              "display" : "Normal"
            }
          ]
        }
      ],
      "referenceRange" : [
        {
          "low" : {
            "value" : 130,
            "unit" : "g/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "g/L"
          },
          "high" : {
            "value" : 170,
            "unit" : "g/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "g/L"
          },
          "text" : "130 – 170 g/L (nam)"
        }
      ]
    },
    {
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "777-3",
            "display" : "Platelets [#/volume] in Blood by Automated count"
          }
        ],
        "text" : "Tiểu cầu (PLT)"
      },
      "valueQuantity" : {
        "value" : 220,
        "unit" : "10^9/L",
        "system" : "http://unitsofmeasure.org",
        "code" : "10*9/L"
      },
      "interpretation" : [
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
              "code" : "N",
              "display" : "Normal"
            }
          ]
        }
      ],
      "referenceRange" : [
        {
          "low" : {
            "value" : 150,
            "unit" : "10^9/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*9/L"
          },
          "high" : {
            "value" : 400,
            "unit" : "10^9/L",
            "system" : "http://unitsofmeasure.org",
            "code" : "10*9/L"
          },
          "text" : "150 – 400 × 10⁹/L"
        }
      ]
    }
  ]
}