Hướng dẫn triển khai FHIR cốt lõi Việt Nam — VN Core FHIR Implementation Guide
0.10.0 - Draft for Community Review
Hướng dẫn triển khai FHIR cốt lõi Việt Nam — VN Core FHIR Implementation Guide - Draft for Community Review (v0.10.0) 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-condition | Phiên bản: 0.10.0 | ||||
| Computable Name: VNCoreCondition | |||||
| Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.47 | |||||
Bản quyền/Pháp lý: Căn cứ hiện hành: TT 06/2026/TT-BYT, QĐ 1849/QĐ-BYT, QĐ 3176/QĐ-BYT đọc cùng QĐ 1931/QĐ-BYT. QĐ 4469/QĐ-BYT và QĐ 98/QĐ-BYT chỉ là provenance lịch sử. |
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Profile Condition cho chẩn đoán tại Việt Nam. Hỗ trợ mã hoá bằng ICD-10 Việt Nam, SNOMED CT trong phạm vi sản phẩm/giấy phép áp dụng và mã YHCT. Profile nền không bắt buộc một coding ICD-10; profile con hoặc workflow báo cáo/KCB có thể siết yêu cầu đó. Căn cứ hiện hành: TT 06/2026/TT-BYT (hiệu lực 01/07/2026) và QĐ 1849/QĐ-BYT về mã hoá ICD-10; QĐ 130/QĐ-BYT, QĐ 4750/QĐ-BYT, QĐ 3176/QĐ-BYT và QĐ 1931/QĐ-BYT cho lớp dữ liệu đầu ra KCB. QĐ 4469/QĐ-BYT và QĐ 98/QĐ-BYT chỉ còn là provenance edition lịch sử.
Usages:
You can also check for usages in the FHIR IG Statistics
Mô tả profile, differential, snapshot và các biểu diễn liên quan.
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
  Condition |
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  clinicalStatus |
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| verificationStatus |
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| category |
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| code |
|
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| bodySite |
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 subject |
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 onset[x] |
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| recorder |
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 note |
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| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std. |
| Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std. |
| Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std. |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item |
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
|
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission |
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
|
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
|
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Condition | 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:   | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
Condition | |||||||||||||
 clinicalStatus |
SO | 0..1 | CodeableConcept | Trạng thái lâm sàng
| ||||||||||
| verificationStatus |
SO | 0..1 | CodeableConcept | Trạng thái xác minh
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Phân loại chẩn đoán
| ||||||||||
| code |
SO | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| ||||||||||
| bodySite |
SO | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | |||||||||||
| onset[x] |
SO | 0..1 | dateTime, Age, Period, Range, string | Thời điểm khởi phát
| ||||||||||
| recordedDate |
0..1 | dateTime | Ngày ghi nhận chẩn đoán | |||||||||||
| recorder |
SO | 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) | Người ghi chẩn đoán
| ||||||||||
| note |
SO | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
| ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
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| clinicalStatus |
|
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| verificationStatus |
|
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| category |
|
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| code |
|
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| bodySite |
|
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| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
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| note |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | Condition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5 | ||||||||||
 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 |
Σ | 0..* | Identifier | External Ids for this condition | ||||||||||
| clinicalStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Phân loại chẩn đoán Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||||
| severity |
0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
 onset[x] |
SOΣ | 0..1 | Thời điểm khởi phát
| |||||||||||
 onsetDateTime |
dateTime | |||||||||||||
| onsetAge |
Age | |||||||||||||
| onsetPeriod |
Period | |||||||||||||
| onsetRange |
Range | |||||||||||||
| onsetString |
string | |||||||||||||
| abatement[x] |
C | 0..1 | When in resolution/remission | |||||||||||
| abatementDateTime |
dateTime | |||||||||||||
| abatementAge |
Age | |||||||||||||
| abatementPeriod |
Period | |||||||||||||
| abatementRange |
Range | |||||||||||||
| abatementString |
string | |||||||||||||
| recordedDate |
Σ | 0..1 | dateTime | Ngày ghi nhận chẩn đoán | ||||||||||
| recorder |
SOΣ | 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) | Người ghi chẩn đoán
| ||||||||||
| asserter |
Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||||||
| stage |
C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1 | ||||||||||
| 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 | ||||||||||
| summary |
C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||||||
| assessment |
C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||||||
| type |
0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||||||
| evidence |
C | 0..* | BackboneElement | Supporting evidence Constraints: con-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 | ||||||||||
| code |
ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||||||||
| detail |
ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||||
| note |
SO | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
| ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std. |
| Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std. |
| Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std. |
| Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📍4.0.1 | FHIR Std. |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std. |
| Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std. |
| Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| con-1 | error | Condition.stage | Stage SHALL have summary or assessment |
summary.exists() or assessment.exists()
|
| con-2 | error | Condition.evidence | evidence SHALL have code or details |
code.exists() or detail.exists()
|
| con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item |
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
|
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission |
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
|
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
|
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Condition | 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 | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 1 element
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Dạng xem phần tử chính
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | Condition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5 | ||||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| clinicalStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Phân loại chẩn đoán Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
| onset[x] |
SOΣ | 0..1 | Thời điểm khởi phát
| |||||||||||
| onsetDateTime |
dateTime | |||||||||||||
| onsetAge |
Age | |||||||||||||
| onsetPeriod |
Period | |||||||||||||
| onsetRange |
Range | |||||||||||||
| onsetString |
string | |||||||||||||
| recordedDate |
Σ | 0..1 | dateTime | Ngày ghi nhận chẩn đoán | ||||||||||
| recorder |
SOΣ | 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) | Người ghi chẩn đoán
| ||||||||||
| note |
SO | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
| ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std. |
| Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std. |
| Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std. |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item |
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
|
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission |
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
|
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
|
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Condition | 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: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
Condition | |||||||||||||
| clinicalStatus |
SO | 0..1 | CodeableConcept | Trạng thái lâm sàng
| ||||||||||
| verificationStatus |
SO | 0..1 | CodeableConcept | Trạng thái xác minh
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Phân loại chẩn đoán
| ||||||||||
| code |
SO | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| ||||||||||
| bodySite |
SO | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | |||||||||||
| onset[x] |
SO | 0..1 | dateTime, Age, Period, Range, string | Thời điểm khởi phát
| ||||||||||
| recordedDate |
0..1 | dateTime | Ngày ghi nhận chẩn đoán | |||||||||||
| recorder |
SO | 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) | Người ghi chẩn đoán
| ||||||||||
| note |
SO | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
| ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
Dạng xem SnapshotView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | Condition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5 | ||||||||||
| 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 |
Σ | 0..* | Identifier | External Ids for this condition | ||||||||||
| clinicalStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Phân loại chẩn đoán Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||||
| severity |
0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
| onset[x] |
SOΣ | 0..1 | Thời điểm khởi phát
| |||||||||||
| onsetDateTime |
dateTime | |||||||||||||
| onsetAge |
Age | |||||||||||||
| onsetPeriod |
Period | |||||||||||||
| onsetRange |
Range | |||||||||||||
| onsetString |
string | |||||||||||||
| abatement[x] |
C | 0..1 | When in resolution/remission | |||||||||||
| abatementDateTime |
dateTime | |||||||||||||
| abatementAge |
Age | |||||||||||||
| abatementPeriod |
Period | |||||||||||||
| abatementRange |
Range | |||||||||||||
| abatementString |
string | |||||||||||||
| recordedDate |
Σ | 0..1 | dateTime | Ngày ghi nhận chẩn đoán | ||||||||||
| recorder |
SOΣ | 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) | Người ghi chẩn đoán
| ||||||||||
| asserter |
Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||||||
| stage |
C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1 | ||||||||||
| 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 | ||||||||||
| summary |
C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||||||
| assessment |
C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||||||
| type |
0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||||||
| evidence |
C | 0..* | BackboneElement | Supporting evidence Constraints: con-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 | ||||||||||
| code |
ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||||||||
| detail |
ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||||
| note |
SO | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
| ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std. |
| Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std. |
| Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std. |
| Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📍4.0.1 | FHIR Std. |
| Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.10.0 | This IG |
| Condition.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std. |
| Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std. |
| Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| con-1 | error | Condition.stage | Stage SHALL have summary or assessment |
summary.exists() or assessment.exists()
|
| con-2 | error | Condition.evidence | evidence SHALL have code or details |
code.exists() or detail.exists()
|
| con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item |
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
|
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission |
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
|
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
|
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Condition | 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 | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| bodySite |
|
| ||
| subject |
|
| ||
| onset[x] |
|
| ||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 1 element
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Biểu diễn khác của hồ sơ: CSV, Excel, Schematron
