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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 & Constraintsdoco
.. 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 & Constraintsdoco
.. 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
... 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
..... data-absent-reason 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 & Constraintsdoco
.. 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 & Constraintsdoco
.. 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
... 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
..... data-absent-reason 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

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredValueSet-VN_Core_Diagnosticreport_Code (a valid code from LOINC)
http://fhir.ehealth.gov.vn/core/ValueSet/vn-core-diagnosticreport-code
from this IG
DiagnosticReport.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA 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()