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-medication-administration | Phiên bản: 0.10.0 | ||||
| Computable Name: VNCoreMedicationAdministration | |||||
| Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.81 | |||||
Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: TT 13/2025/TT-BYT ngày 06/06/2025; Luật Dược 105/2016/QH13 Điều 74; Luật 44/2024/QH15 ngày 21/11/2024; NĐ 163/2025/NĐ-CP ngày 29/06/2025 (thay NĐ 54/2017/NĐ-CP từ 01/07/2025); QĐ 3176/QĐ-BYT ngày 29/10/2024; TT 26/2025/TT-BYT; NĐ 188/2025/NĐ-CP ban hành 01/07/2025, hiệu lực 15/08/2025. |
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Profile MedicationAdministration cho Việt Nam. Ghi nhận sự kiện cho người bệnh dùng thuốc thực tế (điều dưỡng thực hiện y lệnh) — khép chuỗi kê đơn → cấp phát → sử dụng trong điều trị nội trú và bệnh án điện tử. Bổ sung mắt xích còn thiếu so với VNCoreMedicationRequest (y lệnh) và VNCoreMedicationDispense (cấp phát). Căn cứ pháp lý hiện hành:
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) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
  MedicationAdministration |
||
  status |
| |
 category |
| |
 medication[x] |
| |
 subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
 dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.status | Base | required | Medication administration status codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.category | Base | preferred | Medication administration category codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.medication[x] | Base | example | SNOMED CT Medication Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.reasonCode | Base | example | Reason Medication Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | MedicationAdministration | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | MedicationAdministration | 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 | MedicationAdministration | 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 | MedicationAdministration | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | MedicationAdministration | 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()
|
| mad-1 | error | MedicationAdministration.dosage | SHALL have at least one of dosage.dose or dosage.rate[x] |
dose.exists() or rate.exists()
|
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| MedicationAdministration |
C | 0..* | MedicationAdministration | Administration of medication to a patient Constraints: vn-medadmin-completed-inpatient-reference, vn-medadmin-completed-inpatient-context | ||||||
 status |
SO | 1..1 | code | Trạng thái dùng thuốc
| ||||||
| category |
SO | 0..1 | CodeableConcept | Bối cảnh dùng thuốc: inpatient, outpatient, community
| ||||||
 medication[x] |
SO | 1..1 | Thuốc được dùng — mã/tên thuốc, hoặc tham chiếu VNCoreMedication khi cần lô/hạn dùng
| |||||||
 medicationCodeableConcept |
CodeableConcept | |||||||||
| medicationReference |
Reference(Thuốc VN Core — VN Core Medication Profile) | |||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được cho dùng thuốc
| ||||||
| context |
SO | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám/đợt điều trị liên quan
| ||||||
| effective[x] |
SO | 1..1 | dateTime, Period | Thời điểm/khoảng thời gian dùng thuốc (NGAY_TH_YL)
| ||||||
| performer |
SO | 0..* | BackboneElement | Who performed the medication administration and what they did
| ||||||
| actor |
S | 1..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 thực hiện cho dùng thuốc (thường là điều dưỡng) hoặc vai trò hành nghề | ||||||
| reasonCode |
SO | 0..* | CodeableConcept | Lý do dùng thuốc (mã ICD-10 hoặc text)
| ||||||
| request |
SO | 0..1 | Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile) | Y lệnh thuốc tương ứng — bảo toàn chuỗi kê đơn → cấp phát → sử dụng
| ||||||
 dosage |
SO | 0..1 | BackboneElement | Liều dùng thực tế
| ||||||
 route |
S | 0..1 | CodeableConcept | Đường dùng thuốc Binding: Đường dùng thuốc — Vietnam Medication Route ValueSet (extensible) | ||||||
| dose |
S | 0..1 | SimpleQuantity(4.0.1) | Liều một lần dùng | ||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| MedicationAdministration |
C | 0..* | MedicationAdministration | Administration of medication to a patient Constraints: vn-medadmin-completed-inpatient-reference, vn-medadmin-completed-inpatient-context | ||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| identifier |
0..* | Identifier | External identifier | |||||||
| instantiates |
Σ | 0..* | uri | Instantiates protocol or definition | ||||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | Procedure) | Part of referenced event | ||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái dùng thuốc Binding: MedicationAdministration Status Codes (required): A set of codes indicating the current status of a MedicationAdministration.
| ||||||
| statusReason |
0..* | CodeableConcept | Reason administration not performed Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated. | |||||||
| category |
SO | 0..1 | CodeableConcept | Bối cảnh dùng thuốc: inpatient, outpatient, community Binding: MedicationAdministration Category Codes (preferred): A coded concept describing where the medication administered is expected to occur.
| ||||||
| medication[x] |
SOΣ | 1..1 | Thuốc được dùng — mã/tên thuốc, hoặc tham chiếu VNCoreMedication khi cần lô/hạn dùng Binding: SNOMEDCTMedicationCodes (example): Codes identifying substance or product that can be administered.
| |||||||
| medicationCodeableConcept |
CodeableConcept | |||||||||
| medicationReference |
Reference(Thuốc VN Core — VN Core Medication Profile) | |||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được cho dùng thuốc
| ||||||
| context |
SO | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám/đợt điều trị liên quan
| ||||||
| supportingInformation |
0..* | Reference(Resource) | Additional information to support administration | |||||||
| effective[x] |
SOΣ | 1..1 | Thời điểm/khoảng thời gian dùng thuốc (NGAY_TH_YL)
| |||||||
| effectiveDateTime |
dateTime | |||||||||
| effectivePeriod |
Period | |||||||||
| performer |
SOΣ | 0..* | BackboneElement | Who performed the medication administration and what they did
| ||||||
| 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 | ||||||
| function |
0..1 | CodeableConcept | Type of performance Binding: MedicationAdministration Performer Function Codes (example): A code describing the role an individual played in administering the medication. | |||||||
| actor |
SΣ | 1..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 thực hiện cho dùng thuốc (thường là điều dưỡng) hoặc vai trò hành nghề | ||||||
| reasonCode |
SO | 0..* | CodeableConcept | Lý do dùng thuốc (mã ICD-10 hoặc text) Binding: ReasonMedicationGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration was made.
| ||||||
| reasonReference |
0..* | Reference(Condition | Observation | DiagnosticReport) | Condition or observation that supports why the medication was administered | |||||||
| request |
SO | 0..1 | Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile) | Y lệnh thuốc tương ứng — bảo toàn chuỗi kê đơn → cấp phát → sử dụng
| ||||||
| device |
0..* | Reference(Device) | Device used to administer | |||||||
| note |
0..* | Annotation | Information about the administration | |||||||
| dosage |
SOC | 0..1 | BackboneElement | Liều dùng thực tế Constraints: mad-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 | ||||||
| text |
0..1 | string | Free text dosage instructions e.g. SIG | |||||||
| site |
0..1 | CodeableConcept | Body site administered to Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body. | |||||||
| route |
S | 0..1 | CodeableConcept | Đường dùng thuốc Binding: Đường dùng thuốc — Vietnam Medication Route ValueSet (extensible) | ||||||
| method |
0..1 | CodeableConcept | How drug was administered Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered. | |||||||
| dose |
S | 0..1 | SimpleQuantity(4.0.1) | Liều một lần dùng | ||||||
| rate[x] |
0..1 | Dose quantity per unit of time | ||||||||
| rateRatio |
Ratio | |||||||||
| rateQuantity |
Quantity(SimpleQuantity) | |||||||||
| eventHistory |
0..* | Reference(Provenance) | A list of events of interest in the lifecycle | |||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.status | Base | required | Medication administration status codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.statusReason | Base | example | SNOMED CT Reason Medication Not Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.category | Base | preferred | Medication administration category codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.medication[x] | Base | example | SNOMED CT Medication Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.performer.function | Base | example | Medication administration performer function codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.reasonCode | Base | example | Reason Medication Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.site | Base | example | SNOMED CT Anatomical Structure for Administration Site Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| MedicationAdministration.dosage.method | Base | example | SNOMED CT Administration Method Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | MedicationAdministration | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | MedicationAdministration | 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 | MedicationAdministration | 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 | MedicationAdministration | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | MedicationAdministration | 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()
|
| mad-1 | error | MedicationAdministration.dosage | SHALL have at least one of dosage.dose or dosage.rate[x] |
dose.exists() or rate.exists()
|
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
Summary
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Dạng xem phần tử chính
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| MedicationAdministration |
C | 0..* | MedicationAdministration | Administration of medication to a patient Constraints: vn-medadmin-completed-inpatient-reference, vn-medadmin-completed-inpatient-context | ||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái dùng thuốc Binding: MedicationAdministration Status Codes (required): A set of codes indicating the current status of a MedicationAdministration.
| ||||||
| category |
SO | 0..1 | CodeableConcept | Bối cảnh dùng thuốc: inpatient, outpatient, community Binding: MedicationAdministration Category Codes (preferred): A coded concept describing where the medication administered is expected to occur.
| ||||||
| medication[x] |
SOΣ | 1..1 | Thuốc được dùng — mã/tên thuốc, hoặc tham chiếu VNCoreMedication khi cần lô/hạn dùng Binding: SNOMEDCTMedicationCodes (example): Codes identifying substance or product that can be administered.
| |||||||
| medicationCodeableConcept |
CodeableConcept | |||||||||
| medicationReference |
Reference(Thuốc VN Core — VN Core Medication Profile) | |||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được cho dùng thuốc
| ||||||
| context |
SO | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám/đợt điều trị liên quan
| ||||||
| effective[x] |
SOΣ | 1..1 | Thời điểm/khoảng thời gian dùng thuốc (NGAY_TH_YL)
| |||||||
| effectiveDateTime |
dateTime | |||||||||
| effectivePeriod |
Period | |||||||||
| performer |
SOΣ | 0..* | BackboneElement | Who performed the medication administration and what they did
| ||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| actor |
SΣ | 1..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 thực hiện cho dùng thuốc (thường là điều dưỡng) hoặc vai trò hành nghề | ||||||
| reasonCode |
SO | 0..* | CodeableConcept | Lý do dùng thuốc (mã ICD-10 hoặc text) Binding: ReasonMedicationGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration was made.
| ||||||
| request |
SO | 0..1 | Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile) | Y lệnh thuốc tương ứng — bảo toàn chuỗi kê đơn → cấp phát → sử dụng
| ||||||
| dosage |
SOC | 0..1 | BackboneElement | Liều dùng thực tế Constraints: mad-1
| ||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| route |
S | 0..1 | CodeableConcept | Đường dùng thuốc Binding: Đường dùng thuốc — Vietnam Medication Route ValueSet (extensible) | ||||||
| dose |
S | 0..1 | SimpleQuantity(4.0.1) | Liều một lần dùng | ||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.status | Base | required | Medication administration status codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.category | Base | preferred | Medication administration category codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.medication[x] | Base | example | SNOMED CT Medication Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.reasonCode | Base | example | Reason Medication Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | MedicationAdministration | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | MedicationAdministration | 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 | MedicationAdministration | 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 | MedicationAdministration | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | MedicationAdministration | 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()
|
| mad-1 | error | MedicationAdministration.dosage | SHALL have at least one of dosage.dose or dosage.rate[x] |
dose.exists() or rate.exists()
|
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
Dạng xem Differential
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| MedicationAdministration |
C | 0..* | MedicationAdministration | Administration of medication to a patient Constraints: vn-medadmin-completed-inpatient-reference, vn-medadmin-completed-inpatient-context | ||||||
| status |
SO | 1..1 | code | Trạng thái dùng thuốc
| ||||||
| category |
SO | 0..1 | CodeableConcept | Bối cảnh dùng thuốc: inpatient, outpatient, community
| ||||||
| medication[x] |
SO | 1..1 | Thuốc được dùng — mã/tên thuốc, hoặc tham chiếu VNCoreMedication khi cần lô/hạn dùng
| |||||||
| medicationCodeableConcept |
CodeableConcept | |||||||||
| medicationReference |
Reference(Thuốc VN Core — VN Core Medication Profile) | |||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được cho dùng thuốc
| ||||||
| context |
SO | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám/đợt điều trị liên quan
| ||||||
| effective[x] |
SO | 1..1 | dateTime, Period | Thời điểm/khoảng thời gian dùng thuốc (NGAY_TH_YL)
| ||||||
| performer |
SO | 0..* | BackboneElement | Who performed the medication administration and what they did
| ||||||
| actor |
S | 1..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 thực hiện cho dùng thuốc (thường là điều dưỡng) hoặc vai trò hành nghề | ||||||
| reasonCode |
SO | 0..* | CodeableConcept | Lý do dùng thuốc (mã ICD-10 hoặc text)
| ||||||
| request |
SO | 0..1 | Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile) | Y lệnh thuốc tương ứng — bảo toàn chuỗi kê đơn → cấp phát → sử dụng
| ||||||
| dosage |
SO | 0..1 | BackboneElement | Liều dùng thực tế
| ||||||
| route |
S | 0..1 | CodeableConcept | Đường dùng thuốc Binding: Đường dùng thuốc — Vietnam Medication Route ValueSet (extensible) | ||||||
| dose |
S | 0..1 | SimpleQuantity(4.0.1) | Liều một lần dùng | ||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
Dạng xem SnapshotView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| MedicationAdministration |
C | 0..* | MedicationAdministration | Administration of medication to a patient Constraints: vn-medadmin-completed-inpatient-reference, vn-medadmin-completed-inpatient-context | ||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| identifier |
0..* | Identifier | External identifier | |||||||
| instantiates |
Σ | 0..* | uri | Instantiates protocol or definition | ||||||
| partOf |
Σ | 0..* | Reference(MedicationAdministration | Procedure) | Part of referenced event | ||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái dùng thuốc Binding: MedicationAdministration Status Codes (required): A set of codes indicating the current status of a MedicationAdministration.
| ||||||
| statusReason |
0..* | CodeableConcept | Reason administration not performed Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated. | |||||||
| category |
SO | 0..1 | CodeableConcept | Bối cảnh dùng thuốc: inpatient, outpatient, community Binding: MedicationAdministration Category Codes (preferred): A coded concept describing where the medication administered is expected to occur.
| ||||||
| medication[x] |
SOΣ | 1..1 | Thuốc được dùng — mã/tên thuốc, hoặc tham chiếu VNCoreMedication khi cần lô/hạn dùng Binding: SNOMEDCTMedicationCodes (example): Codes identifying substance or product that can be administered.
| |||||||
| medicationCodeableConcept |
CodeableConcept | |||||||||
| medicationReference |
Reference(Thuốc VN Core — VN Core Medication Profile) | |||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được cho dùng thuốc
| ||||||
| context |
SO | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám/đợt điều trị liên quan
| ||||||
| supportingInformation |
0..* | Reference(Resource) | Additional information to support administration | |||||||
| effective[x] |
SOΣ | 1..1 | Thời điểm/khoảng thời gian dùng thuốc (NGAY_TH_YL)
| |||||||
| effectiveDateTime |
dateTime | |||||||||
| effectivePeriod |
Period | |||||||||
| performer |
SOΣ | 0..* | BackboneElement | Who performed the medication administration and what they did
| ||||||
| 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 | ||||||
| function |
0..1 | CodeableConcept | Type of performance Binding: MedicationAdministration Performer Function Codes (example): A code describing the role an individual played in administering the medication. | |||||||
| actor |
SΣ | 1..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 thực hiện cho dùng thuốc (thường là điều dưỡng) hoặc vai trò hành nghề | ||||||
| reasonCode |
SO | 0..* | CodeableConcept | Lý do dùng thuốc (mã ICD-10 hoặc text) Binding: ReasonMedicationGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration was made.
| ||||||
| reasonReference |
0..* | Reference(Condition | Observation | DiagnosticReport) | Condition or observation that supports why the medication was administered | |||||||
| request |
SO | 0..1 | Reference(Đơn thuốc VN Core — VN Core MedicationRequest Profile) | Y lệnh thuốc tương ứng — bảo toàn chuỗi kê đơn → cấp phát → sử dụng
| ||||||
| device |
0..* | Reference(Device) | Device used to administer | |||||||
| note |
0..* | Annotation | Information about the administration | |||||||
| dosage |
SOC | 0..1 | BackboneElement | Liều dùng thực tế Constraints: mad-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 | ||||||
| text |
0..1 | string | Free text dosage instructions e.g. SIG | |||||||
| site |
0..1 | CodeableConcept | Body site administered to Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body. | |||||||
| route |
S | 0..1 | CodeableConcept | Đường dùng thuốc Binding: Đường dùng thuốc — Vietnam Medication Route ValueSet (extensible) | ||||||
| method |
0..1 | CodeableConcept | How drug was administered Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered. | |||||||
| dose |
S | 0..1 | SimpleQuantity(4.0.1) | Liều một lần dùng | ||||||
| rate[x] |
0..1 | Dose quantity per unit of time | ||||||||
| rateRatio |
Ratio | |||||||||
| rateQuantity |
Quantity(SimpleQuantity) | |||||||||
| eventHistory |
0..* | Reference(Provenance) | A list of events of interest in the lifecycle | |||||||
| Documentation for this format | ||||||||||
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
| Path | Status | Usage | ValueSet | Version | Source |
| MedicationAdministration.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.status | Base | required | Medication administration status codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.statusReason | Base | example | SNOMED CT Reason Medication Not Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.category | Base | preferred | Medication administration category codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.medication[x] | Base | example | SNOMED CT Medication Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.performer.function | Base | example | Medication administration performer function codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.reasonCode | Base | example | Reason Medication Given Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.site | Base | example | SNOMED CT Anatomical Structure for Administration Site Codes | 📍4.0.1 | FHIR Std. |
| MedicationAdministration.dosage.route | Base | extensible | Đường dùng thuốc — Vietnam Medication Route ValueSet | 📦0.10.0 | This IG |
| MedicationAdministration.dosage.method | Base | example | SNOMED CT Administration Method Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | MedicationAdministration | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | MedicationAdministration | 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 | MedicationAdministration | 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 | MedicationAdministration | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | MedicationAdministration | 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()
|
| mad-1 | error | MedicationAdministration.dosage | SHALL have at least one of dosage.dose or dosage.rate[x] |
dose.exists() or rate.exists()
|
| vn-medadmin-completed-inpatient-context | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải gắn lượt điều trị (context) — không có encounter thì không đối soát được với hồ sơ nội trú nào. A completed inpatient administration SHALL reference its Encounter. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or context.where(reference.exists() or identifier.exists()).exists()
|
| vn-medadmin-completed-inpatient-reference | error | MedicationAdministration | Sự kiện dùng thuốc nội trú đã hoàn tất phải định danh thuốc bằng Reference(Medication) — mã CodeableConcept đơn thuần không truy vết được chế phẩm/lô đã cấp phát. A completed inpatient administration SHALL identify the administered medication by Reference. |
status != 'completed' or category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/medication-admin-category' and code = 'inpatient').empty() or medication.ofType(Reference).exists()
|
| Name | Kho hồ sơ EMR (Repository) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|
| MedicationAdministration |
||
| status |
| |
| category |
| |
| medication[x] |
| |
| subject |
| |
| context |
| |
| effective[x] |
| |
| performer |
| |
| reasonCode |
| |
| request |
| |
| dosage |
| |
| Documentation for this format | ||
Summary
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Biểu diễn khác của hồ sơ: CSV, Excel, Schematron
