Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.6.0 - Draft for Community Review
Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Draft for Community Review (v0.6.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition-health-checkup | Phiên bản: 0.6.0 | ||||
| Computable Name: VNCoreCompositionHealthCheckup | |||||
Profile Composition cho tài liệu khám sức khỏe định kỳ / khám sàng lọc (Sổ Sức khỏe điện tử) — KHÁC với bệnh án điện tử (xem VNCoreComposition). Đại diện cho mẫu phiếu khám sức khỏe định kỳ (Phụ lục 01) gồm: thông tin hành chính (trên Patient), tiền sử bệnh/tiêm chủng, khám thể lực và khám theo cơ quan, kết luận và phân loại sức khỏe. Căn cứ:
Usages:
You can also check for usages in the FHIR IG Statistics
Mô tả profile, differential, snapshot và các biểu diễn liên quan.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  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 đợt khám sức khỏe (MA_LK) |
| status |
?!SΣ | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type |
SΣ | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) |
 subject |
SΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người được khám sức khỏe |
| encounter |
SΣ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) |
| date |
SΣ | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) |
| 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) | Người khám / cơ sở lập phiếu |
| title |
SΣ | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') |
 attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode |
1..1 | code | professional (người kết luận) | legal (đại diện cơ sở) Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
 party |
0..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) | Who attested the composition | |
| custodian |
SΣ | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) |
  Slices for section |
SC | 0..* | BackboneElement | Composition is broken into sections 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 |
 section:history |
SC | 0..1 | BackboneElement | Tiền sử bệnh/tật, tiền sử gia đình, tiêm chủng Constraints: cmp-1, cmp-2 |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
 code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Khám thể lực và khám theo cơ quan Constraints: cmp-1, cmp-2 |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
 code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |
 entry |
C | 0..* | Reference(Resource) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) |
 section:conclusion |
SC | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) Constraints: cmp-1, cmp-2 |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation 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(Resource) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍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:conclusion.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:history, Composition.section:physicalExam, Composition.section:conclusion | 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:history, Composition.section:physicalExam, Composition.section:conclusion | 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: |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| identifier |
S | 1..1 | Identifier | Mã đợt khám sức khỏe (MA_LK) |
| status |
S | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) |
| type |
S | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) |
| subject |
S | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người được khám sức khỏe |
| encounter |
S | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) |
| date |
S | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) |
| 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) | Người khám / cơ sở lập phiếu |
| title |
S | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') |
| attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) |
| mode |
1..1 | code | professional (người kết luận) | legal (đại diện cơ sở) | |
| party |
0..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) | Who attested the composition | |
| custodian |
S | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) |
| Slices for section |
S | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code |
| section:history |
S | 0..1 | BackboneElement | Tiền sử bệnh/tật, tiền sử gia đình, tiêm chủng |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Khám thể lực và khám theo cơ quan |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |
| entry |
0..* | Reference(Resource) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) | |
| section:conclusion |
S | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation note | |
| entry |
0..* | Reference(Resource) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.type | Base | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| 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 đợt khám sức khỏe (MA_LK) | ||||
| status |
?!SΣ | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) | ||||
| 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) | Người được khám sức khỏe | ||||
| encounter |
SΣ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) | ||||
| date |
SΣ | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) | ||||
| 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) | Người khám / cơ sở lập phiếu | ||||
| title |
SΣ | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) | ||||
| 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 | professional (người kết luận) | legal (đại diện cơ sở) 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(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) | Who attested the composition | |||||
| custodian |
SΣ | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) | ||||
| 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 | Composition is broken into sections 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | A reference to data that supports this section | ||||
| 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, tiền sử gia đình, tiêm chủng 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | A reference to data that supports this section | ||||
| 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 | Khám thể lực và khám theo cơ quan 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) | ||||
| 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:conclusion |
SC | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation 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 | Text summary of the section, for human interpretation 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) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận | ||||
| 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 | ||||||||
| 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 | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
| 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 | 📦2018-08-12 | FHIR Std. |
| 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: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:conclusion.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:history, Composition.section:physicalExam, Composition.section:conclusion | 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:history, Composition.section:physicalExam, Composition.section:conclusion | 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(3 nested mandatory elements)
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Dạng xem phần tử chính
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 đợt khám sức khỏe (MA_LK) |
| status |
?!SΣ | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type |
SΣ | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) |
| subject |
SΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người được khám sức khỏe |
| encounter |
SΣ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) |
| date |
SΣ | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) |
| 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) | Người khám / cơ sở lập phiếu |
| title |
SΣ | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') |
| attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode |
1..1 | code | professional (người kết luận) | legal (đại diện cơ sở) Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| party |
0..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) | Who attested the composition | |
| custodian |
SΣ | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) |
| Slices for section |
SC | 0..* | BackboneElement | Composition is broken into sections 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 |
| section:history |
SC | 0..1 | BackboneElement | Tiền sử bệnh/tật, tiền sử gia đình, tiêm chủng Constraints: cmp-1, cmp-2 |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Khám thể lực và khám theo cơ quan Constraints: cmp-1, cmp-2 |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |
| entry |
C | 0..* | Reference(Resource) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) |
| section:conclusion |
SC | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) Constraints: cmp-1, cmp-2 |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation 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(Resource) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍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:conclusion.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:history, Composition.section:physicalExam, Composition.section:conclusion | 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:history, Composition.section:physicalExam, Composition.section:conclusion | 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: |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| identifier |
S | 1..1 | Identifier | Mã đợt khám sức khỏe (MA_LK) |
| status |
S | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) |
| type |
S | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) |
| subject |
S | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người được khám sức khỏe |
| encounter |
S | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) |
| date |
S | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) |
| 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) | Người khám / cơ sở lập phiếu |
| title |
S | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') |
| attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) |
| mode |
1..1 | code | professional (người kết luận) | legal (đại diện cơ sở) | |
| party |
0..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) | Who attested the composition | |
| custodian |
S | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) |
| Slices for section |
S | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code |
| section:history |
S | 0..1 | BackboneElement | Tiền sử bệnh/tật, tiền sử gia đình, tiêm chủng |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Khám thể lực và khám theo cơ quan |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |
| entry |
0..* | Reference(Resource) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) | |
| section:conclusion |
S | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) |
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation note | |
| entry |
0..* | Reference(Resource) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.type | Base | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
Dạng xem SnapshotView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| 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 đợt khám sức khỏe (MA_LK) | ||||
| status |
?!SΣ | 1..1 | code | Trạng thái tài liệu (preliminary | final | amended) Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Loại tài liệu: 1 trong 17 loại mẫu phiếu KSK (theo nhóm tuổi/đối tượng) Binding: Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet (extensible) | ||||
| 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) | Người được khám sức khỏe | ||||
| encounter |
SΣ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Đợt khám sức khỏe (NGAY_VAO) | ||||
| date |
SΣ | 1..1 | dateTime | Ngày khám sức khỏe (NGAY_VAO) | ||||
| 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) | Người khám / cơ sở lập phiếu | ||||
| title |
SΣ | 1..1 | string | Tiêu đề (vd: 'Giấy khám sức khỏe định kỳ cho người đủ 18 tuổi trở lên') | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
S | 0..* | BackboneElement | Người xác nhận/kết luận (ký số CKS_NGUOI_KET_LUAN) | ||||
| 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 | professional (người kết luận) | legal (đại diện cơ sở) 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(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) | Who attested the composition | |||||
| custodian |
SΣ | 1..1 | Reference(Cơ sở y tế VN Core — VN Core Organization Profile) | Cơ sở KCB thực hiện/lưu trữ (MA_CSKCB / MA_GTIN_CSKCB) | ||||
| 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 | Composition is broken into sections 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | A reference to data that supports this section | ||||
| 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, tiền sử gia đình, tiêm chủng 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | A reference to data that supports this section | ||||
| 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 | Khám thể lực và khám theo cơ quan 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | Text summary of the section, for human interpretation 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) | Observation thể lực / khám cơ quan (vd VNCoreObservationVitalSigns) | ||||
| 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:conclusion |
SC | 0..1 | BackboneElement | Kết luận và phân loại sức khỏe (PHAN_LOAI_SK) 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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: 51848-0 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Evaluation 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 | Text summary of the section, for human interpretation 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) | VNCoreObservationHealthClassification (phân loại Loại I–V) và kết luận | ||||
| 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 | ||||||||
| 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 | extensible | Loại mẫu phiếu khám sức khỏe định kỳ — Vietnam Health Checkup Form Type ValueSet | 📦0.6.0 | This IG |
| 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 | 📦2018-08-12 | FHIR Std. |
| 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: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:conclusion.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:conclusion.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:history, Composition.section:physicalExam, Composition.section:conclusion | 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:history, Composition.section:physicalExam, Composition.section:conclusion | 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(3 nested mandatory elements)
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Biểu diễn khác của hồ sơ: CSV, Excel, Schematron
