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

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Hồ sơ tài nguyên: Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile

Profile Observation cho đánh giá Y học cổ truyền (YHCT) tại Việt Nam theo pattern question/property + coded value (0.10.0):

• Atomic: code = thuộc tính được khám (vn-yhct-observation-attribute-vs: loại mạch, chất lưỡi, rêu lưỡi, triệu chứng vấn chẩn), valueCodeableConcept = finding theo bộ mã dùng chung (vn-yhct-pulse-cs/vn-yhct-tongue-cs/vn-yhct-symptom-cs); mô tả tự do ở value.text/note, KHÔNG dùng valueString.
• Panel tứ chẩn: code = mã panel-*, không value, thành phần nối bằng hasMember.
• Mạch theo bộ vị: Observation loại mạch dùng component.code = bộ vị (tả/hữu × thốn/quan/xích) và component.valueCodeableConcept = finding mạch tại bộ vị đó.

Query một kiểu duy nhất cho finding (toàn cục hoặc theo bộ vị): SearchParameter chuẩn R4 combo-value-concept — CapabilityStatement khai SHALL. Liên kết với VNCoreCondition (chẩn đoán YHCT) và VNCoreProcedure (kỹ thuật YHCT). Căn cứ: QĐ 2552/QĐ-BYT (12/8/2025) — Đợt 1 mã YHCT, QĐ 3080/QĐ-BYT (26/9/2025) — Đợt 2 mã YHCT (hai văn bản ban hành mã FINDING; mã thuộc tính/panel là project-assigned của VN Core — xem vn-yhct-observation-attribute-cs).

Usages:

• Refer to this Profile: Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile
• Examples for this Profile: Observation/ExampleObservationYHCTPanelWithoutMember, Observation/ExampleObservationYHCTPulse, Observation/ExampleObservationYHCTStringResult, Observation/ExampleObservationYHCTSymptom... Show 5 more, Observation/ExampleObservationYHCTSymptomColdAggravation, Observation/ExampleObservationYHCTThietChanPanel, Observation/ExampleObservationYHCTTongue, Observation/ExampleObservationYHCTTongueCoatingThick and Observation/ExampleObservationYHCTTongueCoatingWhite
• CapabilityStatements using this Profile: VN Core EMR Server CapabilityStatement and VN Core Server CapabilityStatement

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.

• Bảng phần tử chính
• Bảng Differential
• Bảng Snapshot
• Nghĩa vụ hỗ trợ
• Thống kê/Tham chiếu
• Tất cả

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7, vn-yhct-no-string-result, vn-yhct-panel-shape
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 đánh giá Binding: ObservationStatus (required): Codes providing the status of an observation. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
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	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
encounter	Σ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SOΣ	0..1		Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
performer	Σ	0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SOΣC	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
hasMember	SOΣ	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
component	SOΣ	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	SΣ	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	SΣ	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Observation.status	Base	required	ObservationStatus	📍4.0.1	FHIR Std.
Observation.category	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.category:YHCT	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present	dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present	value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: vn-yhct-no-string-result, vn-yhct-panel-shape
status	SO	1..1	code	Trạng thái đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
code	SO	1..1	CodeableConcept	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SO	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
encounter		0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SO	0..1	dateTime, Period, Timing, instant	Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
performer		0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SO	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
hasMember	SO	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
component	SO	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
code	S	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	S	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7, vn-yhct-no-string-result, vn-yhct-panel-shape
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. Additional Bindings Purpose AllLanguages Max Binding
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	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!SOΣ	1..1	code	Trạng thái đánh giá Binding: ObservationStatus (required): Codes providing the status of an observation. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
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	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SOΣ	0..1		Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SOΣC	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation Constraints: obs-3
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
low	C	0..1	SimpleQuantity(4.0.1)	Low Range, if relevant
high	C	0..1	SimpleQuantity(4.0.1)	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	SOΣ	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	SOΣ	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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	SΣ	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	SΣ	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Observation.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Observation.status	Base	required	ObservationStatus	📍4.0.1	FHIR Std.
Observation.category	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.category:YHCT	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.dataAbsentReason	Base	extensible	DataAbsentReason	📍4.0.1	FHIR Std.
Observation.interpretation	Base	extensible	Observation Interpretation Codes	📍4.0.1	FHIR Std.
Observation.bodySite	Base	example	SNOMED CT Body Structures	📍4.0.1	FHIR Std.
Observation.method	Base	example	Observation Methods	📍4.0.1	FHIR Std.
Observation.referenceRange.​type	Base	preferred	Observation Reference Range Meaning Codes	📍4.0.1	FHIR Std.
Observation.referenceRange.​appliesTo	Base	example	Observation Reference Range Applies To Codes	📍4.0.1	FHIR Std.
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​dataAbsentReason	Base	extensible	DataAbsentReason	📍4.0.1	FHIR Std.
Observation.component.​interpretation	Base	extensible	Observation Interpretation Codes	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text	low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present	dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present	value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
• Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
• Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
• Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
• Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-yhct)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of Observation.category

Dạng xem phần tử chính

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7, vn-yhct-no-string-result, vn-yhct-panel-shape
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 đánh giá Binding: ObservationStatus (required): Codes providing the status of an observation. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
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	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
encounter	Σ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SOΣ	0..1		Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
performer	Σ	0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SOΣC	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
hasMember	SOΣ	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
component	SOΣ	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	SΣ	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	SΣ	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Observation.status	Base	required	ObservationStatus	📍4.0.1	FHIR Std.
Observation.category	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.category:YHCT	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present	dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present	value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Dạng xem Differential

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: vn-yhct-no-string-result, vn-yhct-panel-shape
status	SO	1..1	code	Trạng thái đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
code	SO	1..1	CodeableConcept	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SO	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
encounter		0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SO	0..1	dateTime, Period, Timing, instant	Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
performer		0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SO	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
hasMember	SO	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
component	SO	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
code	S	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	S	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Dạng xem SnapshotView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7, vn-yhct-no-string-result, vn-yhct-panel-shape
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. Additional Bindings Purpose AllLanguages Max Binding
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	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!SOΣ	1..1	code	Trạng thái đánh giá Binding: ObservationStatus (required): Codes providing the status of an observation. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
Slices for category	SO	1..*	CodeableConcept	Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
category:YHCT	SO	1..1	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: YHCT
display		1..1	string	Representation defined by the system Fixed Value: Y học cổ truyền
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	Thuộc tính được khám (loại mạch, chất lưỡi…) hoặc mã panel tứ chẩn Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
subject	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
focus	Σ	0..*	Reference(Resource)	What the observation is about, when it is not about the subject of record
encounter	Σ	0..1	Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile)	Lượt khám liên quan
effective[x]	SOΣ	0..1		Thời điểm đánh giá Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile)	Lương y / Bác sĩ YHCT thực hiện
value[x]	SOΣC	0..1	CodeableConcept	Finding YHCT (mã dùng chung QĐ 2552/3080) — kèm text mô tả nếu cần Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Nhận xét tổng hợp của thầy thuốc YHCT
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation Constraints: obs-3
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
low	C	0..1	SimpleQuantity(4.0.1)	Low Range, if relevant
high	C	0..1	SimpleQuantity(4.0.1)	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	SOΣ	0..*	Reference(Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile)	Thành phần của panel tứ chẩn (chỉ dùng khi code là panel-*) Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	SOΣ	0..*	BackboneElement	Mạch theo bộ vị (tả/hữu × thốn/quan/xích) — một finding một component Obligations Actor SHALL:populate-if-known Nguồn tạo hồ sơ lâm sàng (Document Source) SHALL:no-error & SHALL:persist Kho hồ sơ EMR (Repository)
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	SΣ	1..1	CodeableConcept	Bộ vị mạch (pulse-left-cun … pulse-right-chi) Binding: Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet (extensible)
value[x]	SΣ	0..1	CodeableConcept	Finding mạch tại bộ vị (vn-yhct-pulse-cs)
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Observation.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Observation.status	Base	required	ObservationStatus	📍4.0.1	FHIR Std.
Observation.category	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.category:YHCT	Base	preferred	Observation Category Codes	📍4.0.1	FHIR Std.
Observation.code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.dataAbsentReason	Base	extensible	DataAbsentReason	📍4.0.1	FHIR Std.
Observation.interpretation	Base	extensible	Observation Interpretation Codes	📍4.0.1	FHIR Std.
Observation.bodySite	Base	example	SNOMED CT Body Structures	📍4.0.1	FHIR Std.
Observation.method	Base	example	Observation Methods	📍4.0.1	FHIR Std.
Observation.referenceRange.​type	Base	preferred	Observation Reference Range Meaning Codes	📍4.0.1	FHIR Std.
Observation.referenceRange.​appliesTo	Base	example	Observation Reference Range Applies To Codes	📍4.0.1	FHIR Std.
Observation.component.​code	Base	extensible	Thuộc tính quan sát tứ chẩn YHCT — VN TCM Observation Attribute ValueSet	📦0.10.0	This IG
Observation.component.​dataAbsentReason	Base	extensible	DataAbsentReason	📍4.0.1	FHIR Std.
Observation.component.​interpretation	Base	extensible	Observation Interpretation Codes	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text	low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present	dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present	value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vn-yhct-no-string-result	error	Observation	Kết quả YHCT mã hoá được phải là CodeableConcept — không dùng valueString ở cả mức Observation lẫn component; mô tả tự do đặt trong value.text hoặc note. Coded TCM findings SHALL NOT be represented as string values.	value.ofType(string).empty() and component.value.ofType(string).empty()
vn-yhct-panel-shape	error	Observation	Observation YHCT mang mã panel (panel-*) không có value/dataAbsentReason/component và phải có hasMember; Observation atomic phải có đúng một trong value/dataAbsentReason và không có hasMember. A TCM panel observation SHALL carry members only; an atomic observation SHALL carry exactly one of value or dataAbsentReason.	(code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).exists() and value.empty() and dataAbsentReason.empty() and component.empty() and hasMember.where(reference.exists() or identifier.exists()).exists()) or (code.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-observation-attribute-cs' and code.startsWith('panel-')).empty() and (value.exists() xor dataAbsentReason.coding.exists()) and hasMember.empty())

Name	Kho hồ sơ EMR (Repository)	Nguồn tạo hồ sơ lâm sàng (Document Source)
Observation
status	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Slices for category	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
category:YHCT	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
code	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
subject	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
effective[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
value[x]	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
hasMember	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
component	SHALL:no-error & SHALL:persist	SHALL:populate-if-known
Documentation for this format

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
• Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
• Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
• Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
• Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-yhct)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of Observation.category