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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 & Constraints    Filter: Filtersdoco
.. 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 Code for the allergy or intolerance reaction manifestation from the SNOMED CT GPS code set

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. AllergyIntolerance SC 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
Constraints: ait-1, ait-2
... 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
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: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 Code for the allergy or intolerance reaction manifestation from the SNOMED CT GPS code set
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 & Constraints    Filter: Filtersdoco
.. 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 Code for the allergy or intolerance reaction manifestation from the SNOMED CT GPS code set

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. AllergyIntolerance SC 0..* AllergyIntoleranceUvIps Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
Constraints: ait-1, ait-2
... 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
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: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 Code for the allergy or intolerance reaction manifestation from the SNOMED CT GPS code set
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

Path Status Usage ValueSet Version Source
AllergyIntolerance.language Base preferred Common Languages 📦4.0.1 FHIR Std.
AllergyIntolerance.clinicalStatus Base required AllergyIntolerance Clinical Status Codes 📍4.0.1 FHIR Std.
AllergyIntolerance.verificationStatus Base required AllergyIntolerance Verification Status Codes 📍4.0.1 FHIR Std.
AllergyIntolerance.type Base required AllergyIntoleranceType 📍4.0.1 FHIR Std.
AllergyIntolerance.category Base required AllergyIntoleranceCategory 📍4.0.1 FHIR Std.
AllergyIntolerance.criticality Base required AllergyIntoleranceCriticality 📍4.0.1 FHIR Std.
AllergyIntolerance.code Base preferred Allergy intolerance substance condition - IPS 📦1.0.0 International Patient Summary Implementation Guide v1.0
AllergyIntolerance.code:allergyIntoleranceGPSCode Base required Allergy intolerance substance condition (GPS) - IPS 📦1.0.0 International Patient Summary Implementation Guide v1.0
AllergyIntolerance.code:absentOrUnknownAllergyIntolerance Base required Absent or Unknown Allergies - IPS 📦1.0.0 International Patient Summary Implementation Guide v1.0
AllergyIntolerance.patient.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
AllergyIntolerance.reaction.​substance Base example Substance Code 📦4.0.1 FHIR Std.
AllergyIntolerance.reaction.​manifestation Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.
AllergyIntolerance.reaction.​manifestation:allergyIntoleranceReactionManifestationGPSCode Base required Allergy Reaction (GPS) - IPS 📦1.0.0 International Patient Summary Implementation Guide v1.0
AllergyIntolerance.reaction.​severity Base required AllergyIntoleranceSeverity 📍4.0.1 FHIR Std.
AllergyIntolerance.reaction.​exposureRoute Base example SNOMED CT Route Codes 📦4.0.1 FHIR Std.

Constraints

Constraints

Id Grade Path(s) Description Expression
ait-1 error AllergyIntolerance AllergyIntolerance.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-2 error AllergyIntolerance AllergyIntolerance.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-2 error AllergyIntolerance If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error AllergyIntolerance 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 AllergyIntolerance 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 AllergyIntolerance If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice AllergyIntolerance 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()