Bản hướng dẫn thực thi (IG) dành các tài liệu lâm sàng
0.0.1 - CI Build
Bản hướng dẫn thực thi (IG) dành các tài liệu lâm sàng
0.0.1 - CI Build
Bản hướng dẫn thực thi (IG) dành các tài liệu lâm sàng, published by Bộ Y tế. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7vn/vn-clin-doc/ and changes regularly. See the Directory of published versions
This profile defines constraints that represent common administrative and demographic concepts for VN clinical documents' header. Further specification, such as type, are provided in document profiles that conform to this profile.
Đường dẫn URL chính thức của Profile này:
http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/VNDocumentHeader
Profile này được dựa trên Resource Composition
Summary
Mandatory: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Profile này được dựa trên Resource Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   versionNumber |
0..1 | integer | Extension URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-VersionNumber | |
| dataEnterer |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-DataEnterer | |
| informant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Informant | |
| informationRecipient |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-InformationRecipient | |
| participant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Participant | |
| performer |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Performer | |
 order |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-service-request) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Order | |
  identifier |
1..1 | Identifier | Version-independent identifier for the Composition | |
 subject |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who and/or what the composition is about | |
| encounter |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-encounter) | Context of the Composition | |
| author |
1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who and/or what authored the composition | |
 Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode, value:party.reference | |
 attester:legal_attester |
0..1 | BackboneElement | Attests to accuracy of composition | |
  party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Who attested the composition | |
| attester:professional_attester |
0..* | BackboneElement | Attests to accuracy of composition | |
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who attested the composition | |
 attester:personal_attester |
0..* | BackboneElement | Attests to accuracy of composition | |
 party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who attested the composition | |
 custodian |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Organization which maintains the composition | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
 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 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber |
0..1 | integer | Extension URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-VersionNumber | |||||
| dataEnterer |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-DataEnterer | |||||
| informant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Informant | |||||
| informationRecipient |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-InformationRecipient | |||||
| participant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Participant | |||||
| performer |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Performer | |||||
| order |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-service-request) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Order | |||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 1..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who and/or what the composition is about | ||||
| encounter |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-encounter) | Context of the Composition | ||||
| date |
Σ | 1..1 | dateTime | Composition editing time | ||||
| author |
Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who and/or what authored the composition | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode, value:party.reference | |||||
| attester:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester |
0..1 | BackboneElement | Attests to accuracy of composition | |||||
 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Who attested the composition | |||||
| attester:professional_attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who attested the composition | |||||
| attester:personal_attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who attested the composition | |||||
| custodian |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
  target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section |
C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
Profile này được dựa trên Resource Composition
Summary
Mandatory: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
Profile này được dựa trên Resource Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| versionNumber |
0..1 | integer | Extension URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-VersionNumber | |
| dataEnterer |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-DataEnterer | |
| informant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Informant | |
| informationRecipient |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-InformationRecipient | |
| participant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Participant | |
| performer |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Performer | |
| order |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-service-request) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Order | |
| identifier |
1..1 | Identifier | Version-independent identifier for the Composition | |
| subject |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who and/or what the composition is about | |
| encounter |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-encounter) | Context of the Composition | |
| author |
1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who and/or what authored the composition | |
| Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode, value:party.reference | |
| attester:legal_attester |
0..1 | BackboneElement | Attests to accuracy of composition | |
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Who attested the composition | |
| attester:professional_attester |
0..* | BackboneElement | Attests to accuracy of composition | |
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who attested the composition | |
| attester:personal_attester |
0..* | BackboneElement | Attests to accuracy of composition | |
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who attested the composition | |
| custodian |
1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Organization which maintains the composition | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| 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 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber |
0..1 | integer | Extension URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-VersionNumber | |||||
| dataEnterer |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-DataEnterer | |||||
| informant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Informant | |||||
| informationRecipient |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-InformationRecipient | |||||
| participant |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Participant | |||||
| performer |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Performer | |||||
| order |
0..* | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-service-request) | Optional Extensions Element URL: http://fhir.ehealth.gov.vn/clindoc/StructureDefinition/Extension-Order | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 1..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who and/or what the composition is about | ||||
| encounter |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-encounter) | Context of the Composition | ||||
| date |
Σ | 1..1 | dateTime | Composition editing time | ||||
| author |
Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who and/or what authored the composition | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| Slices for attester |
0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode, value:party.reference | |||||
| attester:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:legal_attester |
0..1 | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Who attested the composition | |||||
| attester:professional_attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-practitioner) | Who attested the composition | |||||
| attester:personal_attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-patient) | Who attested the composition | |||||
| custodian |
Σ | 1..1 | Reference(http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-provider) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section |
C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
Hình thức mô tả khác: Schematron
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:personal_attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | 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 | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | 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() |
IG © 2020+ Bộ Y tế. Package hl7.fhir.vn.clindoc#0.0.1 based on FHIR 4.0.1. Generated 2024-10-10
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| Version History (Build date: 2024/07/09)
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