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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: VNCoreDiagnosticReport

Thông tin mô tả về báo cáo liên quan đến dịch vụ kỹ thuật/phẫu thuật/thủ thuật

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-diagnostic-report

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 DiagnosticReportUvIps

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

Profile này được dựa trên Resource DiagnosticReportUvIps

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReportUvIps A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... identifier S 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4 | MedicationRequest Profile - VN Core R4) What was requested
... category 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
... subject 1..1 Reference(Patient Profile - VN Core R4) The subject of the report - usually, but not always, the patient
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Health care event when test ordered
... issued S 0..1 instant DateTime this version was made
... performer 0..* Reference(Practitioner Profile - VN Core R4) Responsible Diagnostic Service
... resultsInterpreter 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Practitioner Profile - VN Core R4) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS) | Specimen profile - VN Core R4) Specimens this report is based on
... Slices for result Content/Rules for all slices
.... result:observation-results 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS) | Observation - Laboratory Result Code Profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4 | Observation - Radiology Result Code Profile - VN Core R4) Observations
... imagingStudy S 0..* Reference(ImagingStudy | Imaging Study profile - VN Core R4) Reference to full details of imaging associated with the diagnostic report
... media S 0..* BackboneElement Key images associated with this report
.... link 1..1 Reference(Media | Media Observation profile - VN Core R4) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport S 0..* DiagnosticReportUvIps A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4 | MedicationRequest Profile - VN Core R4) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Fixed Value: final
... category S 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
... code S 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet for Diagnostic Report Code (preferred)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) The subject of the report - usually, but not always, the patient
.... 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 0..1 Reference(Encounter Profile - VN Core R4) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... extension S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Practitioner Profile - VN Core R4) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Practitioner Profile - VN Core R4) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS) | Specimen profile - VN Core R4) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:$this.resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS) | Observation - Laboratory Result Code Profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4 | Observation - Radiology Result Code Profile - VN Core R4) Observations
... imagingStudy S 0..* Reference(ImagingStudy | Imaging Study profile - VN Core R4) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement Key images associated with this report
.... 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
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media | Media Observation profile - VN Core R4) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Profile này được dựa trên Resource DiagnosticReportUvIps

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

Differential View

Profile này được dựa trên Resource DiagnosticReportUvIps

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReportUvIps A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... identifier S 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4 | MedicationRequest Profile - VN Core R4) What was requested
... category 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
... subject 1..1 Reference(Patient Profile - VN Core R4) The subject of the report - usually, but not always, the patient
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Health care event when test ordered
... issued S 0..1 instant DateTime this version was made
... performer 0..* Reference(Practitioner Profile - VN Core R4) Responsible Diagnostic Service
... resultsInterpreter 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Practitioner Profile - VN Core R4) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS) | Specimen profile - VN Core R4) Specimens this report is based on
... Slices for result Content/Rules for all slices
.... result:observation-results 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS) | Observation - Laboratory Result Code Profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4 | Observation - Radiology Result Code Profile - VN Core R4) Observations
... imagingStudy S 0..* Reference(ImagingStudy | Imaging Study profile - VN Core R4) Reference to full details of imaging associated with the diagnostic report
... media S 0..* BackboneElement Key images associated with this report
.... link 1..1 Reference(Media | Media Observation profile - VN Core R4) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... presentedForm S 0..* Attachment Entire report as issued

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport S 0..* DiagnosticReportUvIps A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest | ServiceRequest profile - VN Core R4 | MedicationRequest Profile - VN Core R4) What was requested
... status ?!SΣ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Fixed Value: final
... category S 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
... code S 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet for Diagnostic Report Code (preferred)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) The subject of the report - usually, but not always, the patient
.... 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 0..1 Reference(Encounter Profile - VN Core R4) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... extension S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Practitioner Profile - VN Core R4) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Practitioner Profile - VN Core R4) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS) | Specimen profile - VN Core R4) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:$this.resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS) | Observation - Laboratory Result Code Profile - VN Core R4 | Observation - Pathology Result Code Profile - VN Core R4 | Observation - Radiology Result Code Profile - VN Core R4) Observations
... imagingStudy S 0..* Reference(ImagingStudy | Imaging Study profile - VN Core R4) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement Key images associated with this report
.... 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
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media | Media Observation profile - VN Core R4) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 0..* Attachment Entire report as issued

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
DiagnosticReport.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base preferred ValueSet for Diagnostic Report Code 📦1.0.0 This IG
DiagnosticReport.subject.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.

Constraints

Constraints

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