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-procedure | Phiên bản: 0.10.0 | ||||
| Computable Name: VNCoreProcedure | |||||
| Định danh khác: OID:2.25.161089673617632664299011809196868855799.42.105 | |||||
Profile Procedure cho thủ thuật và dịch vụ kỹ thuật y tế tại Việt Nam. Hỗ trợ mã hoá bằng SNOMED CT IPS Terminology (miễn phí) và danh mục DVKT VN. Căn cứ: TT 23/2024/TT-BYT (danh mục kỹ thuật KCB hiện hành; TT 43/2013/TT-BYT và TT 21/2017/TT-BYT đã hết hiệu lực từ 18/10/2024), QĐ 130/QĐ-BYT (2023), sửa đổi bởi QĐ 3176/QĐ-BYT (2024) — trường MA_DVKT/MA_PTTT_QT trong chuẩn dữ liệu BHXH, QĐ 387/QĐ-BYT (05/02/2026) — ICD-9-CM mới nhất, QĐ 4466/QĐ-BYT (2020) — ánh xạ DVKT ↔ ICD-9-CM.
Usages:
You can also check for usages in the FHIR IG Statistics
Mô tả profile, differential, snapshot và các biểu diễn liên quan.
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
  Procedure |
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  Slices for extension |
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 status |
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 code |
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 subject |
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 performed[x] |
|
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| performer |
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| bodySite |
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 focalDevice |
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| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Procedure | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||||||||
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
   extension:orderDate |
0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date | |||||||||||
 extension:gestationalAge |
0..1 | integer | Tuổi thai tính bằng tuần (TUOI_THAI) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-gestational-age | |||||||||||
 status |
SO | 1..1 | code | Trạng thái thủ thuật
| ||||||||||
| code |
SO | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
| ||||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | |||||||||||
| performed[x] |
SO | 0..1 | dateTime, Period, string, Age, Range | Thời điểm thực hiện
| ||||||||||
| performer |
SO | 0..* | BackboneElement | The people who performed the procedure
| ||||||||||
| 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 | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện | ||||||||||
| bodySite |
SO | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| outcome |
0..1 | CodeableConcept | Kết quả thủ thuật | |||||||||||
| complication |
0..* | CodeableConcept | Biến chứng | |||||||||||
| note |
0..* | Annotation | Ghi chú bổ sung | |||||||||||
 focalDevice |
SO | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
| ||||||||||
 action |
S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred) | ||||||||||
| manipulated |
S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh | ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
| extension:orderDate |
0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date | |||||||||||
| extension:gestationalAge |
0..1 | integer | Tuổi thai tính bằng tuần (TUOI_THAI) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-gestational-age | |||||||||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||||||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||||||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||||||||
| basedOn |
Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||||||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái thủ thuật Binding: EventStatus (required): A code specifying the state of the procedure.
| ||||||||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||||||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
| performed[x] |
SOΣ | 0..1 | Thời điểm thực hiện
| |||||||||||
| performedDateTime |
dateTime | |||||||||||||
| performedPeriod |
Period | |||||||||||||
| performedString |
string | |||||||||||||
| performedAge |
Age | |||||||||||||
| performedRange |
Range | |||||||||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||||||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||||||||
| performer |
SOΣ | 0..* | BackboneElement | The people who performed the procedure
| ||||||||||
| 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 |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||||||||
| 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 | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện | ||||||||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||||||||
| location |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||||||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||||||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| outcome |
Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||||||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||||||||
| complication |
0..* | CodeableConcept | Biến chứng Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||||||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||||||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||||||||
| note |
0..* | Annotation | Ghi chú bổ sung | |||||||||||
| focalDevice |
SO | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
| ||||||||||
| 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 | ||||||||||
| action |
S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred) | ||||||||||
| manipulated |
S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh | ||||||||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||||||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std. |
| Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std. |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Procedure | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 1 element
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Dạng xem phần tử chính
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
| extension:orderDate |
0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date | |||||||||||
| extension:gestationalAge |
0..1 | integer | Tuổi thai tính bằng tuần (TUOI_THAI) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-gestational-age | |||||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái thủ thuật Binding: EventStatus (required): A code specifying the state of the procedure.
| ||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
| performed[x] |
SOΣ | 0..1 | Thời điểm thực hiện
| |||||||||||
| performedDateTime |
dateTime | |||||||||||||
| performedPeriod |
Period | |||||||||||||
| performedString |
string | |||||||||||||
| performedAge |
Age | |||||||||||||
| performedRange |
Range | |||||||||||||
| performer |
SOΣ | 0..* | BackboneElement | The people who performed the procedure
| ||||||||||
| 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 | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện | ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| outcome |
Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||||||||
| complication |
0..* | CodeableConcept | Biến chứng Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||||||||
| note |
0..* | Annotation | Ghi chú bổ sung | |||||||||||
| focalDevice |
SO | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
| ||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||||
| action |
S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred) | ||||||||||
| manipulated |
S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh | ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
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| Slices for extension |
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| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
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| bodySite |
|
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| focalDevice |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Procedure | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Dạng xem Differential
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
| extension:orderDate |
0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date | |||||||||||
| extension:gestationalAge |
0..1 | integer | Tuổi thai tính bằng tuần (TUOI_THAI) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-gestational-age | |||||||||||
| status |
SO | 1..1 | code | Trạng thái thủ thuật
| ||||||||||
| code |
SO | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
| ||||||||||
| subject |
SO | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | |||||||||||
| performed[x] |
SO | 0..1 | dateTime, Period, string, Age, Range | Thời điểm thực hiện
| ||||||||||
| performer |
SO | 0..* | BackboneElement | The people who performed the procedure
| ||||||||||
| 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 | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện | ||||||||||
| bodySite |
SO | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| outcome |
0..1 | CodeableConcept | Kết quả thủ thuật | |||||||||||
| complication |
0..* | CodeableConcept | Biến chứng | |||||||||||
| note |
0..* | Annotation | Ghi chú bổ sung | |||||||||||
| focalDevice |
SO | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
| ||||||||||
| action |
S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred) | ||||||||||
| manipulated |
S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh | ||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
Dạng xem SnapshotView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
| extension:orderDate |
0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date | |||||||||||
| extension:gestationalAge |
0..1 | integer | Tuổi thai tính bằng tuần (TUOI_THAI) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-gestational-age | |||||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||||||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||||||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||||||||
| basedOn |
Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||||||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||||||||
| status |
?!SOΣ | 1..1 | code | Trạng thái thủ thuật Binding: EventStatus (required): A code specifying the state of the procedure.
| ||||||||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||||||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
| ||||||||||
| encounter |
Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan | ||||||||||
| performed[x] |
SOΣ | 0..1 | Thời điểm thực hiện
| |||||||||||
| performedDateTime |
dateTime | |||||||||||||
| performedPeriod |
Period | |||||||||||||
| performedString |
string | |||||||||||||
| performedAge |
Age | |||||||||||||
| performedRange |
Range | |||||||||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||||||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||||||||
| performer |
SOΣ | 0..* | BackboneElement | The people who performed the procedure
| ||||||||||
| 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 |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||||||||
| 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 | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện | ||||||||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||||||||
| location |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||||||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||||||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||||||||
| bodySite |
SOΣ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet (preferred)
| ||||||||||
| outcome |
Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||||||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||||||||
| complication |
0..* | CodeableConcept | Biến chứng Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||||||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||||||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||||||||
| note |
0..* | Annotation | Ghi chú bổ sung | |||||||||||
| focalDevice |
SO | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
| ||||||||||
| 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 | ||||||||||
| action |
S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred) | ||||||||||
| manipulated |
S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh | ||||||||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||||||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||||||||
| Documentation for this format | ||||||||||||||
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.10.0 | This IG |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std. |
| Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std. |
| Procedure.bodySite | Base | preferred | Vị trí trên cơ thể (giải phẫu + huyệt YHCT) — VN Core Body Site ValueSet | 📦0.10.0 | This IG |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | Procedure | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| Name | Bên yêu cầu dữ liệu lõi (Data Requester) | Kho hồ sơ EMR (Repository) | Bên đáp ứng dữ liệu lõi (Data Responder) | Nguồn tạo hồ sơ lâm sàng (Document Source) |
|---|---|---|---|---|
| Procedure |
||||
| Slices for extension |
||||
| status |
|
| ||
| code |
|
| ||
| subject |
|
| ||
| performed[x] |
|
| ||
| performer |
|
| ||
| bodySite |
|
| ||
| focalDevice |
|
| ||
| Documentation for this format | ||||
Summary
Mandatory: 1 element
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Biểu diễn khác của hồ sơ: CSV, Excel, Schematron
