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

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Hồ sơ tài nguyên: Bệnh án điện tử VN Core — VN Core Composition Profile

Profile Composition cho bệnh án điện tử (EMR) Việt Nam. Cấu trúc tài liệu y tế có phân mục: tiền sử, chẩn đoán, xét nghiệm, điều trị, ra viện. Căn cứ: TT 13/2025/TT-BYT (bệnh án điện tử, hiệu lực 21/7/2025), NĐ 137/2024/NĐ-CP (giao dịch điện tử), Luật KCB 2023.

Usages:

• Examples for this Profile: Composition/ExampleCompositionDischargeSummary, Composition/ExampleCompositionEMR and Composition/ExampleCompositionReferralLetter
• CapabilityStatements using this Profile: VN Core EMR Server CapabilityStatement and VN Core Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

Các dạng xem hình thức của nội dung hồ sơ

Mô tả profile, differential, snapshot và các biểu diễn liên quan.

• Bảng phần tử chính
• Bảng Differential
• Bảng Snapshot
• Thống kê/Tham chiếu
• Tất cả

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..1	Identifier	Mã bệnh án
status	?!SΣ	1..1	code	Trạng thái Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Loại bệnh án Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
subject	SΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	SΣ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	SΣ	1..1	dateTime	Ngày lập bệnh án
author	SΣ	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	SΣ	1..1	string	Tiêu đề bệnh án
confidentiality	SΣ	0..1	code	Mức bảo mật Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
custodian	SΣ	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
Slices for section	SC	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
section:chiefComplaint	SC	0..1	BackboneElement	Lý do đến khám / nhập viện Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:history	SC	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:physicalExam	SC	0..1	BackboneElement	Kết quả khám lâm sàng Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:diagnosis	SC	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
section:labResults	SC	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
section:medications	SC	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
section:procedures	SC	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
section:dischargeSummary	SC	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:history.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cmp-1	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section must contain at least one of text, entries, or sub-sections	text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section can only have an emptyReason if it is empty	emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
identifier	S	1..1	Identifier	Mã bệnh án
status	S	1..1	code	Trạng thái
type	S	1..1	CodeableConcept	Loại bệnh án
subject	S	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	S	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	S	1..1	dateTime	Ngày lập bệnh án
author	S	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	S	1..1	string	Tiêu đề bệnh án
confidentiality	S	0..1	code	Mức bảo mật
custodian	S	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
Slices for section	S	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code
section:All Slices				Content/Rules for all slices
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC)
text		0..1	Narrative	Nội dung tường thuật
entry		0..*	Reference(Resource)	Tài nguyên liên quan
section:chiefComplaint	S	0..1	BackboneElement	Lý do đến khám / nhập viện
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
section:history	S	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
section:physicalExam	S	0..1	BackboneElement	Kết quả khám lâm sàng
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
section:diagnosis	S	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN)
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
entry		0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
section:labResults	S	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
entry		0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
section:medications	S	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
entry		0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
section:procedures	S	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
entry		0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
section:dischargeSummary	S	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..1	Identifier	Mã bệnh án
status	?!SΣ	1..1	code	Trạng thái Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Loại bệnh án Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	SΣ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	SΣ	1..1	dateTime	Ngày lập bệnh án
author	SΣ	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	SΣ	1..1	string	Tiêu đề bệnh án
confidentiality	SΣ	0..1	code	Mức bảo mật Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	SΣ	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	SC	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:chiefComplaint	SC	0..1	BackboneElement	Lý do đến khám / nhập viện Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:history	SC	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:physicalExam	SC	0..1	BackboneElement	Kết quả khám lâm sàng Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:diagnosis	SC	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN) Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:labResults	SC	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:medications	SC	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:procedures	SC	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:dischargeSummary	SC	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.attester.​mode	Base	required	CompositionAttestationMode	📍4.0.1	FHIR Std.
Composition.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
Composition.event.code	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.1
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:history.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:history.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:history.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:history.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:labResults.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:labResults.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:medications.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:medications.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:procedures.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:procedures.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cmp-1	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section must contain at least one of text, entries, or sub-sections	text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section can only have an emptyReason if it is empty	emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Summary

Mandatory: 3 elements(8 nested mandatory elements)
Must-Support: 21 elements

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
• Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
• Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
• Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
• Chẩn đoán VN Core — VN Core Condition Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-condition)
• Xét nghiệm VN Core — VN Core Observation Laboratory Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab)
• Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report)
• Đơn thuốc VN Core — VN Core MedicationRequest Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-medication-request)
• Thuốc VN Core — VN Core Medication Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-medication)
• Thủ thuật/DVKT VN Core — VN Core Procedure Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-procedure)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of Composition.section

Dạng xem phần tử chính

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..1	Identifier	Mã bệnh án
status	?!SΣ	1..1	code	Trạng thái Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Loại bệnh án Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
subject	SΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	SΣ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	SΣ	1..1	dateTime	Ngày lập bệnh án
author	SΣ	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	SΣ	1..1	string	Tiêu đề bệnh án
confidentiality	SΣ	0..1	code	Mức bảo mật Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
custodian	SΣ	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
Slices for section	SC	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
section:chiefComplaint	SC	0..1	BackboneElement	Lý do đến khám / nhập viện Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:history	SC	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:physicalExam	SC	0..1	BackboneElement	Kết quả khám lâm sàng Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:diagnosis	SC	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
section:labResults	SC	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
section:medications	SC	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
section:procedures	SC	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
section:dischargeSummary	SC	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:history.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cmp-1	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section must contain at least one of text, entries, or sub-sections	text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section can only have an emptyReason if it is empty	emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Dạng xem Differential

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
identifier	S	1..1	Identifier	Mã bệnh án
status	S	1..1	code	Trạng thái
type	S	1..1	CodeableConcept	Loại bệnh án
subject	S	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	S	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	S	1..1	dateTime	Ngày lập bệnh án
author	S	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	S	1..1	string	Tiêu đề bệnh án
confidentiality	S	0..1	code	Mức bảo mật
custodian	S	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
Slices for section	S	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code
section:All Slices				Content/Rules for all slices
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC)
text		0..1	Narrative	Nội dung tường thuật
entry		0..*	Reference(Resource)	Tài nguyên liên quan
section:chiefComplaint	S	0..1	BackboneElement	Lý do đến khám / nhập viện
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
section:history	S	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
section:physicalExam	S	0..1	BackboneElement	Kết quả khám lâm sàng
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
section:diagnosis	S	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN)
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
entry		0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
section:labResults	S	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
entry		0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
section:medications	S	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
entry		0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
section:procedures	S	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
entry		0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
section:dischargeSummary	S	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp
title		0..1	string	Tên phần
code		1..1	CodeableConcept	Mã phần (LOINC) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
Documentation for this format

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Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..1	Identifier	Mã bệnh án
status	?!SΣ	1..1	code	Trạng thái Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Loại bệnh án Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân
encounter	SΣ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Đợt khám/điều trị
date	SΣ	1..1	dateTime	Ngày lập bệnh án
author	SΣ	1..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Bác sĩ lập bệnh án
title	SΣ	1..1	string	Tiêu đề bệnh án
confidentiality	SΣ	0..1	code	Mức bảo mật Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	SΣ	1..1	Reference(Cơ sở y tế VN Core — VN Core Organization Profile)	CSKCB lưu trữ
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	SC	0..*	BackboneElement	Các phần bệnh án Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	0..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:chiefComplaint	SC	0..1	BackboneElement	Lý do đến khám / nhập viện Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10154-3
display		1..1	string	Representation defined by the system Fixed Value: Chief complaint Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:history	SC	0..1	BackboneElement	Tiền sử bệnh tật, dị ứng, gia đình Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11348-0
display		1..1	string	Representation defined by the system Fixed Value: History of Past illness note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:physicalExam	SC	0..1	BackboneElement	Kết quả khám lâm sàng Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29545-1
display		1..1	string	Representation defined by the system Fixed Value: Physical findings note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:diagnosis	SC	0..1	BackboneElement	Chẩn đoán sơ bộ và xác định (ICD-10 VN) Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29548-5
display		1..1	string	Representation defined by the system Fixed Value: Diagnosis Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Chẩn đoán VN Core — VN Core Condition Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:labResults	SC	0..1	BackboneElement	Kết quả xét nghiệm, chẩn đoán hình ảnh Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		1..1	string	Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Xét nghiệm VN Core — VN Core Observation Laboratory Profile | Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:medications	SC	0..1	BackboneElement	Đơn thuốc, y lệnh dùng thuốc Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		1..1	string	Representation defined by the system Fixed Value: History of Medication use Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile | Thuốc VN Core — VN Core Medication Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:procedures	SC	0..1	BackboneElement	Thủ thuật, phẫu thuật đã thực hiện Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		1..1	string	Representation defined by the system Fixed Value: History of Procedures Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Thủ thuật/DVKT VN Core — VN Core Procedure Profile)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:dischargeSummary	SC	0..1	BackboneElement	Tình trạng ra viện, hướng điều trị tiếp Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Tên phần
code	S	1..1	CodeableConcept	Mã phần (LOINC) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18842-5
display		1..1	string	Representation defined by the system Fixed Value: Discharge summary
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Nội dung tường thuật This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	Tài nguyên liên quan
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.attester.​mode	Base	required	CompositionAttestationMode	📍4.0.1	FHIR Std.
Composition.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
Composition.event.code	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.1
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:chiefComplaint.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:history.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:history.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:history.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:history.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:physicalExam.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:diagnosis.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:labResults.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:labResults.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:labResults.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:medications.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:medications.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:medications.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:procedures.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:procedures.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:procedures.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:dischargeSummary.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cmp-1	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section must contain at least one of text, entries, or sub-sections	text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:chiefComplaint, Composition.section:history, Composition.section:physicalExam, Composition.section:diagnosis, Composition.section:labResults, Composition.section:medications, Composition.section:procedures, Composition.section:dischargeSummary	A section can only have an emptyReason if it is empty	emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Summary

Mandatory: 3 elements(8 nested mandatory elements)
Must-Support: 21 elements

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
• Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
• Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
• Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
• Chẩn đoán VN Core — VN Core Condition Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-condition)
• Xét nghiệm VN Core — VN Core Observation Laboratory Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab)
• Báo cáo cận lâm sàng VN Core — VN Core DiagnosticReport Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report)
• Đơn thuốc VN Core — VN Core MedicationRequest Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-medication-request)
• Thuốc VN Core — VN Core Medication Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-medication)
• Thủ thuật/DVKT VN Core — VN Core Procedure Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-procedure)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of Composition.section