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)

Bản thô xml | Tải xuống


<Observation xmlns="http://hl7.org/fhir">
  <id value="ExampleObservationLabCBC"/>
  <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" 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>
</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>
  </text>
  <status value="final"/>
  <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="58410-2"/>
      <display value="CBC panel - Blood by Automated count"/>
    </coding>
    <text value="Công thức máu (CBC)"/>
  </code>
  <subject>🔗 
    <reference value="Patient/ExamplePatientNguyenVanAn"/>
    <display value="Nguyễn Văn An"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/ExampleEncounterOutpatient"/>
  </encounter>
  <effectiveDateTime value="2026-04-20T07:45:00+07:00"/>
  <performer>🔗 
    <reference value="Practitioner/ExamplePractitionerBSCKII"/>
    <display value="BS CKII Nguyễn Thị Lan"/>
  </performer>
  <interpretation>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
      <code value="A"/>
      <display value="Abnormal"/>
    </coding>
  </interpretation>
  <note>
    <text
          value="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."/>
  </note>
  <specimen>🔗 
    <reference value="Specimen/ExampleSpecimenWholeBloodCBC"/>
    <display value="Mẫu máu toàn phần chống đông EDTA"/>
  </specimen>
  <component>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="6690-2"/>
        <display value="Leukocytes [#/volume] in Blood by Automated count"/>
      </coding>
      <text value="Bạch cầu (WBC)"/>
    </code>
    <valueQuantity>
      <value value="12.8"/>
      <unit value="10^9/L"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="10*9/L"/>
    </valueQuantity>
    <interpretation>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
        <code value="H"/>
        <display value="High"/>
      </coding>
    </interpretation>
    <referenceRange>
      <low>
        <value value="4"/>
        <unit value="10^9/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*9/L"/>
      </low>
      <high>
        <value value="10"/>
        <unit value="10^9/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*9/L"/>
      </high>
      <text value="4.0 – 10.0 × 10⁹/L"/>
    </referenceRange>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="789-8"/>
        <display value="Erythrocytes [#/volume] in Blood by Automated count"/>
      </coding>
      <text value="Hồng cầu (RBC)"/>
    </code>
    <valueQuantity>
      <value value="4.6"/>
      <unit value="10^12/L"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="10*12/L"/>
    </valueQuantity>
    <interpretation>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
        <code value="N"/>
        <display value="Normal"/>
      </coding>
    </interpretation>
    <referenceRange>
      <low>
        <value value="4"/>
        <unit value="10^12/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*12/L"/>
      </low>
      <high>
        <value value="5.5"/>
        <unit value="10^12/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*12/L"/>
      </high>
      <text value="4.0 – 5.5 × 10¹²/L (nam)"/>
    </referenceRange>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="718-7"/>
        <display value="Hemoglobin [Mass/volume] in Blood"/>
      </coding>
      <text value="Hemoglobin (Hgb)"/>
    </code>
    <valueQuantity>
      <value value="138"/>
      <unit value="g/L"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="g/L"/>
    </valueQuantity>
    <interpretation>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
        <code value="N"/>
        <display value="Normal"/>
      </coding>
    </interpretation>
    <referenceRange>
      <low>
        <value value="130"/>
        <unit value="g/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="g/L"/>
      </low>
      <high>
        <value value="170"/>
        <unit value="g/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="g/L"/>
      </high>
      <text value="130 – 170 g/L (nam)"/>
    </referenceRange>
  </component>
  <component>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="777-3"/>
        <display value="Platelets [#/volume] in Blood by Automated count"/>
      </coding>
      <text value="Tiểu cầu (PLT)"/>
    </code>
    <valueQuantity>
      <value value="220"/>
      <unit value="10^9/L"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="10*9/L"/>
    </valueQuantity>
    <interpretation>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
        <code value="N"/>
        <display value="Normal"/>
      </coding>
    </interpretation>
    <referenceRange>
      <low>
        <value value="150"/>
        <unit value="10^9/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*9/L"/>
      </low>
      <high>
        <value value="400"/>
        <unit value="10^9/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="10*9/L"/>
      </high>
      <text value="150 – 400 × 10⁹/L"/>
    </referenceRange>
  </component>
</Observation>