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-diagnosis | Phiên bản: 0.10.0 | ||||
| Computable Name: VNCoreConditionDiagnosis | |||||
| Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.46 | |||||
Bản quyền/Pháp lý: Căn cứ hiện hành: TT 06/2026/TT-BYT (ban hành 02/04/2026, hiệu lực 01/07/2026), QĐ 1849/QĐ-BYT ngày 23/06/2026 và QĐ 3176/QĐ-BYT ngày 29/10/2024 (MA_BENH_CHINH, MA_BENH_KT). QĐ 4469/QĐ-BYT và QĐ 98/QĐ-BYT chỉ dùng để truy vết edition cũ. |
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Profile con của VNCoreCondition cho chẩn đoán được ghi nhận trong một lượt khám/điều trị tại Việt Nam. Profile này yêu cầu một coding ICD-10 VN để hỗ trợ chẩn đoán lượt khám, mã hoá bệnh tật và ánh xạ dữ liệu đầu ra KCB trong phạm vi áp dụng; không suy rộng thành yêu cầu cho mọi Condition ngoài workflow đó. Căn cứ hiện hành là TT 06/2026/TT-BYT (hiệu lực 01/07/2026) và hướng dẫn kỹ thuật QĐ 1849/QĐ-BYT; QĐ 4469/QĐ-BYT và QĐ 98/QĐ-BYT chỉ còn là provenance của edition lịch sử. Category được cố định là encounter-diagnosis để phù hợp ghi nhận chẩn đoán trong hồ sơ KCB và dữ liệu đầu ra theo QĐ 3176/QĐ-BYT (29/10/2024), trường MA_BENH_CHINH (01 mã bệnh chính) và MA_BENH_KT (tối đa 12 mã bệnh kèm theo).
Usages:
You can also check for usages in the FHIR IG Statistics
Mô tả profile, differential, snapshot và các biểu diễn liên quan.
| Name | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
  Condition |
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  Slices for extension |
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   extension:dueTo |
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  clinicalStatus |
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| verificationStatus |
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| category |
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| code |
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 Slices for coding |
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| bodySite |
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 subject |
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| encounter |
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 onset[x] |
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 recordedDate |
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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.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 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()
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| 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()
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| 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()
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| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
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| 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()
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| 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()
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| dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
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| dom-6 | best practice | Condition | A resource should have narrative for robust management |
text.`div`.exists()
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| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
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| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
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| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses | |||||||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||
 extension:dueTo |
SO | 0..* | (Complex) | Chẩn đoán nguyên nhân của biểu hiện này (cặp dagger/asterisk ICD-10) URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
| ||||||
  value[x] |
S | 1..1 | Reference(Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile) | Value of extension | ||||||
 category |
1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám 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://terminology.hl7.org/CodeSystem/condition-category | |||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis | |||||||
| code |
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| Slices for coding |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |||||||
 coding:icd10vn |
S | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required) | ||||||
  system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-icd10-cs | |||||||
| code |
S | 1..1 | code | Mã bệnh ICD-10 VN | ||||||
| display |
S | 0..1 | string | Tên chẩn đoán ICD-10 VN | ||||||
| coding:icd10who |
0..1 | Coding | Mã ICD-10 quốc tế (WHO) — tuỳ chọn, cho liên thông quốc tế | |||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10 | |||||||
| code |
1..1 | code | Mã ICD-10 WHO | |||||||
| coding:snomedct |
S | 0..1 | Coding | Mã SNOMED CT tương đương | ||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||||
| code |
S | 1..1 | code | Mã SNOMED CT | ||||||
| display |
S | 0..1 | string | Tên chẩn đoán SNOMED CT | ||||||
| coding:yhct |
0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT | |||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs | |||||||
| code |
1..1 | code | Mã U YHCT | |||||||
| display |
0..1 | string | Tên bệnh danh/thể lâm sàng YHCT | |||||||
| encounter |
SO | 1..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám mang chẩn đoán này (bắt buộc với encounter-diagnosis)
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| recordedDate |
SO | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
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| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| Condition |
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| Slices for extension |
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| extension:dueTo |
| |
| encounter |
| |
| recordedDate |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.10.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | VNCoreCondition | 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 | ||||||||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||||||||||
| extension:dueTo |
SO | 0..* | (Complex) | Chẩn đoán nguyên nhân của biểu hiện này (cặp dagger/asterisk ICD-10) URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
| |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | |||||||||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | ||||||||||||||||
| value[x] |
S | 1..1 | Reference(Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile) | Value of extension | |||||||||||||||
 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 | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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://terminology.hl7.org/CodeSystem/condition-category | ||||||||||||||||
| version |
0..1 | string | Version of the system - if relevant | ||||||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | ||||||||||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis | ||||||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | ||||||||||||||||
| text |
0..1 | string | Plain text representation of the concept | ||||||||||||||||
| 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)
| |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| Slices for coding |
Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |||||||||||||||
| coding:icd10vn |
SΣ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required) | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-icd10-cs | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã bệnh ICD-10 VN | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán ICD-10 VN | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:icd10who |
Σ | 0..1 | Coding | Mã ICD-10 quốc tế (WHO) — tuỳ chọn, cho liên thông quốc tế | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10 | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
Σ | 1..1 | code | Mã ICD-10 WHO | |||||||||||||||
| display |
Σ | 0..1 | string | Representation defined by the system | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:snomedct |
SΣ | 0..1 | Coding | Mã SNOMED CT tương đương | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã SNOMED CT | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán SNOMED CT | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:yhct |
Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
Σ | 1..1 | code | Mã U YHCT | |||||||||||||||
| display |
Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | |||||||||||||||
| 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 |
SOΣ | 1..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám mang chẩn đoán này (bắt buộc với encounter-diagnosis)
| |||||||||||||||
| 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 |
SOΣ | 1..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 | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
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| Slices for extension |
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| extension:dueTo |
| |||
| clinicalStatus |
|
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| verificationStatus |
|
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| category |
|
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| code |
|
| ||
| Slices for coding |
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| bodySite |
|
| ||
| subject |
|
| ||
| encounter |
| |||
| onset[x] |
|
| ||
| recordedDate |
| |||
| 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.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 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 | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| Slices for extension |
||||
| extension:dueTo |
| |||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| Slices for coding |
||||
| bodySite |
|
| ||
| subject |
|
| ||
| encounter |
| |||
| onset[x] |
|
| ||
| recordedDate |
| |||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 7 elements(6 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Dạng xem phần tử chính
| Name | Flags | Card. | Type | Description & Constraints Filter: | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | VNCoreCondition | 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 | |||||||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||||||||||
| extension:dueTo |
SO | 0..* | (Complex) | Chẩn đoán nguyên nhân của biểu hiện này (cặp dagger/asterisk ICD-10) URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
| |||||||||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | |||||||||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | ||||||||||||||||
| value[x] |
S | 1..1 | Reference(Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile) | Value of extension | |||||||||||||||
| 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 | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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://terminology.hl7.org/CodeSystem/condition-category | ||||||||||||||||
| version |
0..1 | string | Version of the system - if relevant | ||||||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | ||||||||||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis | ||||||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | ||||||||||||||||
| text |
0..1 | string | Plain text representation of the concept | ||||||||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
| |||||||||||||||
| Slices for coding |
Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |||||||||||||||
| coding:icd10vn |
SΣ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required) | |||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-icd10-cs | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã bệnh ICD-10 VN | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán ICD-10 VN | |||||||||||||||
| coding:icd10who |
Σ | 0..1 | Coding | Mã ICD-10 quốc tế (WHO) — tuỳ chọn, cho liên thông quốc tế | |||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10 | |||||||||||||||
| code |
Σ | 1..1 | code | Mã ICD-10 WHO | |||||||||||||||
| coding:snomedct |
SΣ | 0..1 | Coding | Mã SNOMED CT tương đương | |||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã SNOMED CT | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán SNOMED CT | |||||||||||||||
| coding:yhct |
Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs | |||||||||||||||
| code |
Σ | 1..1 | code | Mã U YHCT | |||||||||||||||
| display |
Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| 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 |
SOΣ | 1..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám mang chẩn đoán này (bắt buộc với encounter-diagnosis)
| |||||||||||||||
| onset[x] |
SOΣ | 0..1 | Thời điểm khởi phát
| ||||||||||||||||
| onsetDateTime |
dateTime | ||||||||||||||||||
| onsetAge |
Age | ||||||||||||||||||
| onsetPeriod |
Period | ||||||||||||||||||
| onsetRange |
Range | ||||||||||||||||||
| onsetString |
string | ||||||||||||||||||
| recordedDate |
SOΣ | 1..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 | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| Slices for extension |
||||
| extension:dueTo |
| |||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| Slices for coding |
||||
| bodySite |
|
| ||
| subject |
|
| ||
| encounter |
| |||
| onset[x] |
|
| ||
| recordedDate |
| |||
| 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.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 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 |
0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses | |||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||
| extension:dueTo |
SO | 0..* | (Complex) | Chẩn đoán nguyên nhân của biểu hiện này (cặp dagger/asterisk ICD-10) URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
| ||||||
| value[x] |
S | 1..1 | Reference(Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile) | Value of extension | ||||||
| category |
1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám 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://terminology.hl7.org/CodeSystem/condition-category | |||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis | |||||||
| code |
||||||||||
| Slices for coding |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |||||||
| coding:icd10vn |
S | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required) | ||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-icd10-cs | |||||||
| code |
S | 1..1 | code | Mã bệnh ICD-10 VN | ||||||
| display |
S | 0..1 | string | Tên chẩn đoán ICD-10 VN | ||||||
| coding:icd10who |
0..1 | Coding | Mã ICD-10 quốc tế (WHO) — tuỳ chọn, cho liên thông quốc tế | |||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10 | |||||||
| code |
1..1 | code | Mã ICD-10 WHO | |||||||
| coding:snomedct |
S | 0..1 | Coding | Mã SNOMED CT tương đương | ||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||||
| code |
S | 1..1 | code | Mã SNOMED CT | ||||||
| display |
S | 0..1 | string | Tên chẩn đoán SNOMED CT | ||||||
| coding:yhct |
0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT | |||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs | |||||||
| code |
1..1 | code | Mã U YHCT | |||||||
| display |
0..1 | string | Tên bệnh danh/thể lâm sàng YHCT | |||||||
| encounter |
SO | 1..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám mang chẩn đoán này (bắt buộc với encounter-diagnosis)
| ||||||
| recordedDate |
SO | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
| ||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| Condition |
||
| Slices for extension |
||
| extension:dueTo |
| |
| encounter |
| |
| recordedDate |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.10.0 | This IG |
Dạng xem SnapshotView
| Name | Flags | Card. | Type | Description & Constraints Filter: | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | VNCoreCondition | 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 | ||||||||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||||||||||
| extension:dueTo |
SO | 0..* | (Complex) | Chẩn đoán nguyên nhân của biểu hiện này (cặp dagger/asterisk ICD-10) URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
| |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | |||||||||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | ||||||||||||||||
| value[x] |
S | 1..1 | Reference(Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile) | Value of extension | |||||||||||||||
| 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 | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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://terminology.hl7.org/CodeSystem/condition-category | ||||||||||||||||
| version |
0..1 | string | Version of the system - if relevant | ||||||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | ||||||||||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis | ||||||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | ||||||||||||||||
| text |
0..1 | string | Plain text representation of the concept | ||||||||||||||||
| 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)
| |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| Slices for coding |
Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |||||||||||||||
| coding:icd10vn |
SΣ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required) | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-icd10-cs | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã bệnh ICD-10 VN | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán ICD-10 VN | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:icd10who |
Σ | 0..1 | Coding | Mã ICD-10 quốc tế (WHO) — tuỳ chọn, cho liên thông quốc tế | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10 | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
Σ | 1..1 | code | Mã ICD-10 WHO | |||||||||||||||
| display |
Σ | 0..1 | string | Representation defined by the system | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:snomedct |
SΣ | 0..1 | Coding | Mã SNOMED CT tương đương | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
SΣ | 1..1 | code | Mã SNOMED CT | |||||||||||||||
| display |
SΣ | 0..1 | string | Tên chẩn đoán SNOMED CT | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| coding:yhct |
Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | ||||||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||||||||||||
| system |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs | |||||||||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | |||||||||||||||
| code |
Σ | 1..1 | code | Mã U YHCT | |||||||||||||||
| display |
Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT | |||||||||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | |||||||||||||||
| 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 |
SOΣ | 1..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám mang chẩn đoán này (bắt buộc với encounter-diagnosis)
| |||||||||||||||
| 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 |
SOΣ | 1..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 | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| Slices for extension |
||||
| extension:dueTo |
| |||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| Slices for coding |
||||
| bodySite |
|
| ||
| subject |
|
| ||
| encounter |
| |||
| onset[x] |
|
| ||
| recordedDate |
| |||
| 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.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 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 | Kho hồ sơ EMR (Repository) | Bên yêu cầu dữ liệu lõi (Data Requester) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Condition |
||||
| Slices for extension |
||||
| extension:dueTo |
| |||
| clinicalStatus |
|
| ||
| verificationStatus |
|
| ||
| category |
|
| ||
| code |
|
| ||
| Slices for coding |
||||
| bodySite |
|
| ||
| subject |
|
| ||
| encounter |
| |||
| onset[x] |
|
| ||
| recordedDate |
| |||
| recorder |
|
| ||
| note |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 7 elements(6 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Biểu diễn khác của hồ sơ: CSV, Excel, Schematron
