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Bản hướng dẫn thực thi (IG) dành cho các hệ thống thông tin Y tế tại Việt Nam
1.0.0 - CI Build

Bản hướng dẫn thực thi (IG) dành cho các hệ thống thông tin Y tế tại Việt Nam, published by Cục Công nghệ thông tin - Bộ Y tế. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7vn/vn-core-ig/ and changes regularly. See the Directory of published versions

Resource Profile: VNCoreAllergyIntolerance

Thông tin mô tả về dị ứng bệnh nhân gặp phải

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-allergy-intolerance

Nội dung Profile

Thông tin bổ sung cho các thông tin hiển thị (Nội dung mô tả, Differential Table, Snapshot Table, ...).

Profile này được dựa trên Resource AllergyIntoleranceUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. AllergyIntolerance 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
... clinicalStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... verificationStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... category S 0..* code food | medication | environment | biologic
... patient 1..1 Reference(Patient Profile - VN Core R4) Who the sensitivity is for
... encounter 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter when the allergy or intolerance was asserted
... asserter 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Source of the information about the allergy
... reaction
.... Slices for manifestation Content/Rules for all slices
..... manifestation:allergyIntoleranceReactionManifestationGPSCode 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. AllergyIntolerance SC 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
ait-1: AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error.
ait-2: AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... abatement-datetime S 0..1 dateTime Abatement datetime
URL: http://hl7.org/fhir/uv/ips/StructureDefinition/abatement-dateTime-uv-ips
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External ids for this item
... clinicalStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: AllergyIntoleranceClinicalStatusCodes (required): The clinical status of the allergy or intolerance.

... verificationStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: AllergyIntoleranceVerificationStatusCodes (required): Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified substance.

... type SΣ 0..1 code allergy | intolerance - Underlying mechanism (if known)
Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk.

... category SΣ 0..* code food | medication | environment | biologic
Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances.


... criticality SΣ 0..1 code low | high | unable-to-assess
Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.

... Slices for code SΣ 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: Allergy intolerance substance condition - IPS (preferred): Type of the substance/product, allergy or intolerance condition.

.... code:allergyIntoleranceGPSCode S 0..1 CodeableConceptIPS Code for allergy or intolerance from the SNOMED CT GPS code set
Binding: Allergy intolerance substance condition (GPS) - IPS (required): Codes for allergy or intolerance from the SNOMED CT GPS code set

.... code:absentOrUnknownAllergyIntolerance S 0..1 CodeableConceptIPS Code for absent or unknown allergy or intolerance
Binding: Absent or Unknown Allergies - IPS (required): negation/exclusion codes for reporting no known allergies or not available data.

... patient SΣ 1..1 Reference(Patient Profile - VN Core R4) Who the sensitivity is for
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter when the allergy or intolerance was asserted
... Slices for onset[x] 0..1 dateTime When allergy or intolerance was identified
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime S 0..1 dateTime When allergy or intolerance was identified
... recordedDate 0..1 dateTime Date first version of the resource instance was recorded
... recorder 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the sensitivity
... asserter SΣ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Source of the information about the allergy
... lastOccurrence 0..1 dateTime Date(/time) of last known occurrence of a reaction
... note 0..* Annotation Additional text not captured in other fields
... reaction S 0..* BackboneElement Adverse Reaction Events linked to exposure to substance
.... 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
.... substance 0..1 CodeableConcept Specific substance or pharmaceutical product considered to be responsible for event
Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products).

.... Slices for manifestation S 1..* CodeableConceptIPS Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Clinical symptoms and/or signs that are observed or associated with an Adverse Reaction Event.


..... manifestation:allergyIntoleranceReactionManifestationGPSCode S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Allergy Reaction (GPS) - IPS (required)
.... description 0..1 string Description of the event as a whole
.... onset S 0..1 dateTime Date(/time) when manifestations showed
.... severity S 0..1 code mild | moderate | severe (of event as a whole)
Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.

.... exposureRoute 0..1 CodeableConcept How the subject was exposed to the substance
Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.

.... note 0..* Annotation Text about event not captured in other fields

doco Documentation for this format

Differential View

Profile này được dựa trên Resource AllergyIntoleranceUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. AllergyIntolerance 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
... clinicalStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... verificationStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... category S 0..* code food | medication | environment | biologic
... patient 1..1 Reference(Patient Profile - VN Core R4) Who the sensitivity is for
... encounter 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter when the allergy or intolerance was asserted
... asserter 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Source of the information about the allergy
... reaction
.... Slices for manifestation Content/Rules for all slices
..... manifestation:allergyIntoleranceReactionManifestationGPSCode 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. AllergyIntolerance SC 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
ait-1: AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error.
ait-2: AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... abatement-datetime S 0..1 dateTime Abatement datetime
URL: http://hl7.org/fhir/uv/ips/StructureDefinition/abatement-dateTime-uv-ips
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External ids for this item
... clinicalStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: AllergyIntoleranceClinicalStatusCodes (required): The clinical status of the allergy or intolerance.

... verificationStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: AllergyIntoleranceVerificationStatusCodes (required): Assertion about certainty associated with a propensity, or potential risk, of a reaction to the identified substance.

... type SΣ 0..1 code allergy | intolerance - Underlying mechanism (if known)
Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk.

... category SΣ 0..* code food | medication | environment | biologic
Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances.


... criticality SΣ 0..1 code low | high | unable-to-assess
Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.

... Slices for code SΣ 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: Allergy intolerance substance condition - IPS (preferred): Type of the substance/product, allergy or intolerance condition.

.... code:allergyIntoleranceGPSCode S 0..1 CodeableConceptIPS Code for allergy or intolerance from the SNOMED CT GPS code set
Binding: Allergy intolerance substance condition (GPS) - IPS (required): Codes for allergy or intolerance from the SNOMED CT GPS code set

.... code:absentOrUnknownAllergyIntolerance S 0..1 CodeableConceptIPS Code for absent or unknown allergy or intolerance
Binding: Absent or Unknown Allergies - IPS (required): negation/exclusion codes for reporting no known allergies or not available data.

... patient SΣ 1..1 Reference(Patient Profile - VN Core R4) Who the sensitivity is for
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter when the allergy or intolerance was asserted
... Slices for onset[x] 0..1 dateTime When allergy or intolerance was identified
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime S 0..1 dateTime When allergy or intolerance was identified
... recordedDate 0..1 dateTime Date first version of the resource instance was recorded
... recorder 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the sensitivity
... asserter SΣ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Source of the information about the allergy
... lastOccurrence 0..1 dateTime Date(/time) of last known occurrence of a reaction
... note 0..* Annotation Additional text not captured in other fields
... reaction S 0..* BackboneElement Adverse Reaction Events linked to exposure to substance
.... 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
.... substance 0..1 CodeableConcept Specific substance or pharmaceutical product considered to be responsible for event
Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products).

.... Slices for manifestation S 1..* CodeableConceptIPS Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: SNOMEDCTClinicalFindings (example): Clinical symptoms and/or signs that are observed or associated with an Adverse Reaction Event.


..... manifestation:allergyIntoleranceReactionManifestationGPSCode S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Allergy Reaction (GPS) - IPS (required)
.... description 0..1 string Description of the event as a whole
.... onset S 0..1 dateTime Date(/time) when manifestations showed
.... severity S 0..1 code mild | moderate | severe (of event as a whole)
Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.

.... exposureRoute 0..1 CodeableConcept How the subject was exposed to the substance
Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.

.... note 0..* Annotation Text about event not captured in other fields

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSetURI
AllergyIntolerance.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
AllergyIntolerance.clinicalStatusrequiredAllergyIntoleranceClinicalStatusCodes
http://hl7.org/fhir/ValueSet/allergyintolerance-clinical|4.0.1
from the FHIR Standard
AllergyIntolerance.verificationStatusrequiredAllergyIntoleranceVerificationStatusCodes
http://hl7.org/fhir/ValueSet/allergyintolerance-verification|4.0.1
from the FHIR Standard
AllergyIntolerance.typerequiredAllergyIntoleranceType
http://hl7.org/fhir/ValueSet/allergy-intolerance-type|4.0.1
from the FHIR Standard
AllergyIntolerance.categoryrequiredAllergyIntoleranceCategory
http://hl7.org/fhir/ValueSet/allergy-intolerance-category|4.0.1
from the FHIR Standard
AllergyIntolerance.criticalityrequiredAllergyIntoleranceCriticality
http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality|4.0.1
from the FHIR Standard
AllergyIntolerance.codepreferredAllergyIntoleranceSubstanceConditionUvIps
http://hl7.org/fhir/uv/ips/ValueSet/allergy-intolerance-substance-condition-uv-ips
AllergyIntolerance.code:allergyIntoleranceGPSCoderequiredAllergyintolerancesubstanceconditionGPS
http://hl7.org/fhir/uv/ips/ValueSet/allergy-intolerance-substance-condition-gps-uv-ips
AllergyIntolerance.code:absentOrUnknownAllergyIntolerancerequiredNoAllergiesInfoUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-allergies-uv-ips
AllergyIntolerance.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
AllergyIntolerance.reaction.substanceexampleSubstanceCode
http://hl7.org/fhir/ValueSet/substance-code
from the FHIR Standard
AllergyIntolerance.reaction.manifestationexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
AllergyIntolerance.reaction.manifestation:allergyIntoleranceReactionManifestationGPSCoderequiredAllergyReactionGpsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/allergy-reaction-gps-uv-ips
AllergyIntolerance.reaction.severityrequiredAllergyIntoleranceSeverity
http://hl7.org/fhir/ValueSet/reaction-event-severity|4.0.1
from the FHIR Standard
AllergyIntolerance.reaction.exposureRouteexampleSNOMEDCTRouteCodes
http://hl7.org/fhir/ValueSet/route-codes
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
ait-1errorAllergyIntoleranceAllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error.
: verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists()
ait-2errorAllergyIntoleranceAllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty()
dom-2errorAllergyIntoleranceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorAllergyIntoleranceIf 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-4errorAllergyIntoleranceIf 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-5errorAllergyIntoleranceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceAllergyIntoleranceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()