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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: VNCoreConditionEncounterDiagnosis

Thông tin mô tả về chẩn đoán bệnh tại đợt khám, chữa bệnh

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-condition-encounter-diagnosis

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 ConditionUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition ConditionUvIps
... identifier S 0..* Identifier External Ids for this condition
... clinicalStatus 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... verificationStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display 1..1 string Representation defined by the system
Fixed Value: Encounter Diagnosis
... Slices for code Content/Rules for all slices
.... code:conditionCode 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã bệnh tật (required): vnConditonCode

... bodySite S 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
... subject 1..1 Reference(Patient Profile - VN Core R4) Who has the condition?
... encounter S 1..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... recordedDate S 0..1 dateTime Date record was first recorded
... recorder S 0..1 Reference(Practitioner Profile - VN Core R4) Who recorded the condition
... asserter 0..1 Reference(Practitioner Profile - VN Core R4) Person who asserts this condition
... stage S 0..* BackboneElement Stage/grade, usually assessed formally
.... summary 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... type 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... evidence
.... code 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SC 0..* ConditionUvIps Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier External Ids for this condition
... clinicalStatus S 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category S 1..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Problem Type - IPS (extensible)

Fixed Value: As shown
.... id 0..0 string Unique id for inter-element referencing
.... extension 0..0 Extension Additional content defined by implementations
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version 0..0 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display 1..1 string Representation defined by the system
Fixed Value: Encounter Diagnosis
..... userSelected 0..0 boolean If this coding was chosen directly by the user
.... text 0..0 string Plain text representation of the concept
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Problem Severity - IPS (preferred)
... Slices for code SΣ 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

.... code:problemGPSCode SΣ 0..1 CodeableConcept Code for a problem from the SNOMED CT GPS code set
Binding: CORE Problem List Finding/Situation/Event (GPS) - IPS (required): problemGPS

.... code:absentOrUnknownProblem SΣ 0..1 CodeableConcept Code for absent problem or for unknown problem
Binding: Absent or Unknown Problems - IPS (required): Absent problem or unknown problem

.... code:conditionCode SΣ 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã bệnh tật (required): vnConditonCode

... bodySite S 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who has the condition?
.... 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 SΣ 1..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
.... onset[x]:onsetPeriod Σ 0..1 Period Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
.... abatement[x]:abatementPeriod C 0..1 Period When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder SΣ 0..1 Reference(Practitioner Profile - VN Core R4) Who recorded the condition
... asserter SΣ 0..1 Reference(Practitioner Profile - VN Core R4) Person who asserts this condition
... stage SC 0..* BackboneElement Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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
.... summary 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C 0..* BackboneElement Supporting evidence
con-2: evidence SHALL have code or details
.... 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 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Differential View

Profile này được dựa trên Resource ConditionUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition ConditionUvIps
... identifier S 0..* Identifier External Ids for this condition
... clinicalStatus 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... verificationStatus 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display 1..1 string Representation defined by the system
Fixed Value: Encounter Diagnosis
... Slices for code Content/Rules for all slices
.... code:conditionCode 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã bệnh tật (required): vnConditonCode

... bodySite S 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
... subject 1..1 Reference(Patient Profile - VN Core R4) Who has the condition?
... encounter S 1..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... recordedDate S 0..1 dateTime Date record was first recorded
... recorder S 0..1 Reference(Practitioner Profile - VN Core R4) Who recorded the condition
... asserter 0..1 Reference(Practitioner Profile - VN Core R4) Person who asserts this condition
... stage S 0..* BackboneElement Stage/grade, usually assessed formally
.... summary 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... type 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... evidence
.... code 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SC 0..* ConditionUvIps Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier External Ids for this condition
... clinicalStatus S 1..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category S 1..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Problem Type - IPS (extensible)

Fixed Value: As shown
.... id 0..0 string Unique id for inter-element referencing
.... extension 0..0 Extension Additional content defined by implementations
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version 0..0 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
..... display 1..1 string Representation defined by the system
Fixed Value: Encounter Diagnosis
..... userSelected 0..0 boolean If this coding was chosen directly by the user
.... text 0..0 string Plain text representation of the concept
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Problem Severity - IPS (preferred)
... Slices for code SΣ 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

.... code:problemGPSCode SΣ 0..1 CodeableConcept Code for a problem from the SNOMED CT GPS code set
Binding: CORE Problem List Finding/Situation/Event (GPS) - IPS (required): problemGPS

.... code:absentOrUnknownProblem SΣ 0..1 CodeableConcept Code for absent problem or for unknown problem
Binding: Absent or Unknown Problems - IPS (required): Absent problem or unknown problem

.... code:conditionCode SΣ 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã bệnh tật (required): vnConditonCode

... bodySite S 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who has the condition?
.... 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 SΣ 1..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
.... onset[x]:onsetPeriod Σ 0..1 Period Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
.... abatement[x]:abatementPeriod C 0..1 Period When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder SΣ 0..1 Reference(Practitioner Profile - VN Core R4) Who recorded the condition
... asserter SΣ 0..1 Reference(Practitioner Profile - VN Core R4) Person who asserts this condition
... stage SC 0..* BackboneElement Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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
.... summary 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C 0..* BackboneElement Supporting evidence
con-2: evidence SHALL have code or details
.... 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 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleFixed Value: encounter-diagnosis("Encounter Diagnosis")
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.severitypreferredProblemSeverityUvIps
http://hl7.org/fhir/uv/ips/ValueSet/condition-severity-uv-ips
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.code:problemGPSCoderequiredCoreProblemListFindingSituationEventGpsUvIps
http://hl7.org/fhir/uv/ips/ValueSet/core-problem-finding-situation-event-gps-uv-ips
Condition.code:absentOrUnknownProblemrequiredNoProbsInfoUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips
Condition.code:conditionCoderequiredValueSet-VN_Core_Condition_Code
http://fhir.ehealth.gov.vn/core/ValueSet/vn-core-condition-code
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA 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()