HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.4.0 - STU1 Draft Viet Nam cờ

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Local Development build (v0.4.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Hồ sơ tài nguyên: Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-condition-diagnosis Phiên bản: 0.4.0
Computable Name: VNCoreConditionDiagnosis

Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: QĐ 4469/QĐ-BYT ngày 28/10/2020; QĐ 98/QĐ-BYT ngày 14/01/2022; TT 06/2026/TT-BYT ngày 02/04/2026; QĐ 3176/QĐ-BYT ngày 29/10/2024 (MA_BENH/MA_BENHKHAC).

Profile con của VNCoreCondition cho chẩn đoán được ghi nhận trong một lượt khám/điều trị tại Việt Nam. ICD-10 VN là coding bắt buộc theo QĐ 4469/QĐ-BYT (28/10/2020), bổ sung mã COVID-19 theo QĐ 98/QĐ-BYT (14/01/2022) và hướng dẫn mã hóa theo TT 06/2026/TT-BYT (02/04/2026). 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/MA_BENHKHAC.

Usages:

You can also check for usages in the FHIR IG Statistics

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!SΣC 0..1 CodeableConcept Trạng thái lâm sàng
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... category S 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 SΣ 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://hl7.org/fhir/sid/icd-10
...... code SΣ 1..1 code Mã bệnh ICD-10 VN
...... display SΣ 0..1 string Tên chẩn đoán ICD-10 VN
..... 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 SΣ 0..* CodeableConcept Vị trí giải phẫu
Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... onset[x] SΣ 0..1 Thời điểm khởi phát
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... recordedDate SΣ 1..1 dateTime Ngày ghi nhận chẩn đoán
... recorder SΣ 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 S 0..* Annotation Ghi chú lâm sàng về chẩn đoán

doco Documentation for this format

Terminology Bindings

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 📦0.4.0 This IG
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG
Condition.bodySite Base preferred Vị trí giải phẫu — VN Core Body Site ValueSet 📦0.4.0 This IG

Constraints

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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* VNCoreCondition Detailed information about conditions, problems or diagnoses
... 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://hl7.org/fhir/sid/icd-10
...... code S 1..1 code Mã bệnh ICD-10 VN
...... display S 0..1 string Tên chẩn đoán ICD-10 VN
..... 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 S 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 ?!SΣC 0..1 CodeableConcept Trạng thái lâm sàng
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 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 S 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 SΣ 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://hl7.org/fhir/sid/icd-10
...... 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: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 SΣ 0..* CodeableConcept Vị trí giải phẫu
Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... onset[x] SΣ 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 SΣ 1..1 dateTime Ngày ghi nhận chẩn đoán
... recorder SΣ 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 S 0..* Annotation Ghi chú lâm sàng về chẩn đoán

doco Documentation for this format

Terminology Bindings

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 📦0.4.0 This IG
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG
Condition.bodySite Base preferred Vị trí giải phẫu — VN Core Body Site ValueSet 📦0.4.0 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.

Constraints

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()

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 8 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the values of Condition.code.coding

Dạng xem phần tử chính

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!SΣC 0..1 CodeableConcept Trạng thái lâm sàng
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... category S 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 SΣ 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://hl7.org/fhir/sid/icd-10
...... code SΣ 1..1 code Mã bệnh ICD-10 VN
...... display SΣ 0..1 string Tên chẩn đoán ICD-10 VN
..... 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 SΣ 0..* CodeableConcept Vị trí giải phẫu
Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... onset[x] SΣ 0..1 Thời điểm khởi phát
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... recordedDate SΣ 1..1 dateTime Ngày ghi nhận chẩn đoán
... recorder SΣ 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 S 0..* Annotation Ghi chú lâm sàng về chẩn đoán

doco Documentation for this format

Terminology Bindings

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 📦0.4.0 This IG
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG
Condition.bodySite Base preferred Vị trí giải phẫu — VN Core Body Site ValueSet 📦0.4.0 This IG

Constraints

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* VNCoreCondition Detailed information about conditions, problems or diagnoses
... 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://hl7.org/fhir/sid/icd-10
...... code S 1..1 code Mã bệnh ICD-10 VN
...... display S 0..1 string Tên chẩn đoán ICD-10 VN
..... 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 S 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG

Dạng xem SnapshotView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 ?!SΣC 0..1 CodeableConcept Trạng thái lâm sàng
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 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 S 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 SΣ 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://hl7.org/fhir/sid/icd-10
...... 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: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 SΣ 0..* CodeableConcept Vị trí giải phẫu
Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... encounter SΣ 0..1 Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
... onset[x] SΣ 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 SΣ 1..1 dateTime Ngày ghi nhận chẩn đoán
... recorder SΣ 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 S 0..* Annotation Ghi chú lâm sàng về chẩn đoán

doco Documentation for this format

Terminology Bindings

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 📦0.4.0 This IG
Condition.code.coding:icd10vn Base required ICD-10 Việt Nam — VN ICD-10 ValueSet 📦0.4.0 This IG
Condition.bodySite Base preferred Vị trí giải phẫu — VN Core Body Site ValueSet 📦0.4.0 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.

Constraints

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()

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 8 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the values of Condition.code.coding

 

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