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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: VNCoreEncounter

Thông tin mô tả về đợt khám, chữa bệnh.

Đường dẫn URL chính thức của Profile này: 

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

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 Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter Encounter
... Slices for identifier 0..* Identifier Identifier(s) by which this encounter is known
Slice: Unordered, Open by value:system
.... identifier:MaBenhAn 0..1 Identifier Identifier(s) by which this encounter is known
..... use 1..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/MRN
..... value 1..1 string The value that is unique
.... identifier:MaDotThamKham 0..1 Identifier Identifier(s) by which this encounter is known
..... use 1..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: VN
....... display 1..1 string Representation defined by the system
Fixed Value: Visit number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/VisitNumber
..... value 1..1 string The value that is unique
.... identifier:MaLuuTru 0..1 Identifier Identifier(s) by which this encounter is known
..... use 0..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/ArchiveNumber
..... value 1..1 string The value that is unique
... status S 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class 1..1 VNCoreCoding Classification of patient encounter
.... class 1..1 VNCoreCoding inpatient | outpatient | ambulatory | emergency +
... type S 0..* VNCoreCodeableConcept Specific type of encounter
... serviceType S 0..1 VNCoreCodeableConcept Specific type of service
... priority 0..1 VNCoreCodeableConcept Indicates the urgency of the encounter
... subject S 0..1 Reference(Patient Profile - VN Core R4) The patient or group present at the encounter
... basedOn S 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant S 0..* BackboneElement List of participants involved in the encounter
.... type 0..* VNCoreCodeableConcept Role of participant in encounter
... appointment S 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode S 0..* VNCoreCodeableConcept Coded reason the encounter takes place
... reasonReference S 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... Slices for diagnosis S 0..* BackboneElement The list of diagnosis relevant to this encounter
Slice: Unordered, Open by value:use.coding.system, value:use.coding.code
.... diagnosis:All Slices Content/Rules for all slices
..... condition 1..1 Reference(Condition - Encounter Diagnosis- VN Core R4) The diagnosis or procedure relevant to the encounter
.... diagnosis:AdmissionDiagnosis-CDVaoVien 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AD
....... display 1..1 string Representation defined by the system
Fixed Value: Admission diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: Admission diagnosis
..... rank 0..0
.... diagnosis:DischargeDiagnosis-CDRaVien 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DD
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: Discharge diagnosis
..... rank 0..0
.... diagnosis:ChiefComplaint_CDBenhChinh 1..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CC
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint
...... text 1..1 string Plain text representation of the concept
Fixed Value: Chief complaint
..... rank 0..0
.... diagnosis:ComorbidityDiagnosis-CDBenhPhu 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CM
....... display 1..1 string Representation defined by the system
Fixed Value: Comorbidity diagnosis
.... diagnosis:Pre_opDiagnosis_CDTruocPTTT 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pre-op
....... display 1..1 string Representation defined by the system
Fixed Value: pre-op diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: pre-op diagnosis
.... diagnosis:Post_opDiagnosis_CDSauPTTT 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: post-op
....... display 1..1 string Representation defined by the system
Fixed Value: post-op diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: post-op diagnosis
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... preAdmissionIdentifier S 0..1 Identifier Pre-admission identifier
.... origin S 0..1 Reference(Location | Organization) The location/organization from which the patient came before admission
.... admitSource S 0..1 VNCoreCodeableConcept From where patient was admitted (physician referral, transfer)
.... reAdmission S 0..1 VNCoreCodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
.... dietPreference 0..* VNCoreCodeableConcept Diet preferences reported by the patient
.... specialCourtesy 0..* VNCoreCodeableConcept Special courtesies (VIP, board member)
.... specialArrangement 0..* VNCoreCodeableConcept Wheelchair, translator, stretcher, etc.
.... destination S 0..1 Reference(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 VNCoreCodeableConcept Category or kind of location after discharge
... location S 0..* BackboneElement List of locations where the patient has been
.... location 1..1 Reference(Location Profile - VN Core R4) Location the encounter takes place
... serviceProvider S 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) The organization (facility) responsible for this encounter
... partOf S 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* Encounter An interaction during which services are provided to the patient
... 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
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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
... Slices for identifier Σ 0..* Identifier Identifier(s) by which this encounter is known
Slice: Unordered, Open by value:system
.... identifier:MaBenhAn Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/MRN
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:MaDotThamKham Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: VN
....... display 1..1 string Representation defined by the system
Fixed Value: Visit number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/VisitNumber
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:MaLuuTru Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/ArchiveNumber
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..* BackboneElement List of past encounter statuses
.... 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
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1 Period The time that the episode was in the specified status
... class Σ 1..1 VNCoreCoding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory S 0..* BackboneElement List of past encounter classes
.... 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
.... class 1..1 VNCoreCoding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1 Period The time that the episode was in the specified class
... type SΣ 0..* VNCoreCodeableConcept Specific type of encounter
Binding: EncounterType (example): The type of encounter.


... serviceType SΣ 0..1 VNCoreCodeableConcept Specific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1 VNCoreCodeableConcept Indicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣ 0..1 Reference(Patient Profile - VN Core R4) The patient or group present at the encounter
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn S 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... 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
.... type Σ 0..* VNCoreCodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period 0..1 Period Period of time during the encounter that the participant participated
.... individual Σ 0..1 Reference(Practitioner | PractitionerRole | RelatedPerson) Persons involved in the encounter other than the patient
... appointment SΣ 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* VNCoreCodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference SΣ 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... Slices for diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
Slice: Unordered, Open by value:use.coding.system, value:use.coding.code
.... diagnosis:All Slices Content/Rules for all slices
..... 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
..... condition Σ 1..1 Reference(Condition - Encounter Diagnosis- VN Core R4) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:AdmissionDiagnosis-CDVaoVien Σ 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AD
....... display 1..1 string Representation defined by the system
Fixed Value: Admission diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Admission diagnosis
.... diagnosis:DischargeDiagnosis-CDRaVien Σ 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DD
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Discharge diagnosis
.... diagnosis:ChiefComplaint_CDBenhChinh Σ 1..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CC
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Chief complaint
.... diagnosis:ComorbidityDiagnosis-CDBenhPhu Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CM
....... display 1..1 string Representation defined by the system
Fixed Value: Comorbidity diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:Pre_opDiagnosis_CDTruocPTTT Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pre-op
....... display 1..1 string Representation defined by the system
Fixed Value: pre-op diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: pre-op diagnosis
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:Post_opDiagnosis_CDSauPTTT Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: post-op
....... display 1..1 string Representation defined by the system
Fixed Value: post-op diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: post-op diagnosis
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
... account 0..* Reference(Account) The set of accounts that may be used for billing for this Encounter
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... 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
.... preAdmissionIdentifier S 0..1 Identifier Pre-admission identifier
.... origin S 0..1 Reference(Location | Organization) The location/organization from which the patient came before admission
.... admitSource S 0..1 VNCoreCodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 VNCoreCodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dietPreference 0..* VNCoreCodeableConcept Diet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


.... specialCourtesy 0..* VNCoreCodeableConcept Special courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred): Special courtesies.


.... specialArrangement 0..* VNCoreCodeableConcept Wheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred): Special arrangements.


.... destination S 0..1 Reference(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 VNCoreCodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... 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
.... location 1..1 Reference(Location Profile - VN Core R4) Location the encounter takes place
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1 CodeableConcept The physical type of the location (usually the level in the location hierachy - bed room ward etc.)
Binding: LocationType (example): Physical form of the location.

.... period 0..1 Period Time period during which the patient was present at the location
... serviceProvider S 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) The organization (facility) responsible for this encounter
... partOf S 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format

Differential View

Profile này được dựa trên Resource Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter Encounter
... Slices for identifier 0..* Identifier Identifier(s) by which this encounter is known
Slice: Unordered, Open by value:system
.... identifier:MaBenhAn 0..1 Identifier Identifier(s) by which this encounter is known
..... use 1..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/MRN
..... value 1..1 string The value that is unique
.... identifier:MaDotThamKham 0..1 Identifier Identifier(s) by which this encounter is known
..... use 1..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: VN
....... display 1..1 string Representation defined by the system
Fixed Value: Visit number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/VisitNumber
..... value 1..1 string The value that is unique
.... identifier:MaLuuTru 0..1 Identifier Identifier(s) by which this encounter is known
..... use 0..1 code usual | official | temp | secondary | old (If known)
Fixed Value: official
..... type 0..1 CodeableConcept Description of identifier
Fixed Value: As shown
...... 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/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
..... system 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/ArchiveNumber
..... value 1..1 string The value that is unique
... status S 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class 1..1 VNCoreCoding Classification of patient encounter
.... class 1..1 VNCoreCoding inpatient | outpatient | ambulatory | emergency +
... type S 0..* VNCoreCodeableConcept Specific type of encounter
... serviceType S 0..1 VNCoreCodeableConcept Specific type of service
... priority 0..1 VNCoreCodeableConcept Indicates the urgency of the encounter
... subject S 0..1 Reference(Patient Profile - VN Core R4) The patient or group present at the encounter
... basedOn S 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant S 0..* BackboneElement List of participants involved in the encounter
.... type 0..* VNCoreCodeableConcept Role of participant in encounter
... appointment S 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode S 0..* VNCoreCodeableConcept Coded reason the encounter takes place
... reasonReference S 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... Slices for diagnosis S 0..* BackboneElement The list of diagnosis relevant to this encounter
Slice: Unordered, Open by value:use.coding.system, value:use.coding.code
.... diagnosis:All Slices Content/Rules for all slices
..... condition 1..1 Reference(Condition - Encounter Diagnosis- VN Core R4) The diagnosis or procedure relevant to the encounter
.... diagnosis:AdmissionDiagnosis-CDVaoVien 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AD
....... display 1..1 string Representation defined by the system
Fixed Value: Admission diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: Admission diagnosis
..... rank 0..0
.... diagnosis:DischargeDiagnosis-CDRaVien 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DD
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: Discharge diagnosis
..... rank 0..0
.... diagnosis:ChiefComplaint_CDBenhChinh 1..1 BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CC
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint
...... text 1..1 string Plain text representation of the concept
Fixed Value: Chief complaint
..... rank 0..0
.... diagnosis:ComorbidityDiagnosis-CDBenhPhu 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CM
....... display 1..1 string Representation defined by the system
Fixed Value: Comorbidity diagnosis
.... diagnosis:Pre_opDiagnosis_CDTruocPTTT 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pre-op
....... display 1..1 string Representation defined by the system
Fixed Value: pre-op diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: pre-op diagnosis
.... diagnosis:Post_opDiagnosis_CDSauPTTT 0..* BackboneElement The list of diagnosis relevant to this encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Required Pattern: At least the following
...... coding 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/diagnosis-role
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: post-op
....... display 1..1 string Representation defined by the system
Fixed Value: post-op diagnosis
...... text 1..1 string Plain text representation of the concept
Fixed Value: post-op diagnosis
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... preAdmissionIdentifier S 0..1 Identifier Pre-admission identifier
.... origin S 0..1 Reference(Location | Organization) The location/organization from which the patient came before admission
.... admitSource S 0..1 VNCoreCodeableConcept From where patient was admitted (physician referral, transfer)
.... reAdmission S 0..1 VNCoreCodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
.... dietPreference 0..* VNCoreCodeableConcept Diet preferences reported by the patient
.... specialCourtesy 0..* VNCoreCodeableConcept Special courtesies (VIP, board member)
.... specialArrangement 0..* VNCoreCodeableConcept Wheelchair, translator, stretcher, etc.
.... destination S 0..1 Reference(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 VNCoreCodeableConcept Category or kind of location after discharge
... location S 0..* BackboneElement List of locations where the patient has been
.... location 1..1 Reference(Location Profile - VN Core R4) Location the encounter takes place
... serviceProvider S 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) The organization (facility) responsible for this encounter
... partOf S 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* Encounter An interaction during which services are provided to the patient
... 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
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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
... Slices for identifier Σ 0..* Identifier Identifier(s) by which this encounter is known
Slice: Unordered, Open by value:system
.... identifier:MaBenhAn Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/MRN
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:MaDotThamKham Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: VN
....... display 1..1 string Representation defined by the system
Fixed Value: Visit number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/VisitNumber
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:MaLuuTru Σ 0..1 Identifier Identifier(s) by which this encounter is known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


Fixed Value: official
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/v2-0203
....... version 0..0 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MR
....... display 1..1 string Representation defined by the system
Fixed Value: Medical record number
....... userSelected 0..0 boolean If this coding was chosen directly by the user
...... text 0..0 string Plain text representation of the concept
..... system Σ 1..1 uri The namespace for the identifier value
Fixed Value: http://fhir.ehealth.gov.vn/core/sid/ArchiveNumber
..... value Σ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..* BackboneElement List of past encounter statuses
.... 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
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1 Period The time that the episode was in the specified status
... class Σ 1..1 VNCoreCoding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory S 0..* BackboneElement List of past encounter classes
.... 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
.... class 1..1 VNCoreCoding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1 Period The time that the episode was in the specified class
... type SΣ 0..* VNCoreCodeableConcept Specific type of encounter
Binding: EncounterType (example): The type of encounter.


... serviceType SΣ 0..1 VNCoreCodeableConcept Specific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1 VNCoreCodeableConcept Indicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣ 0..1 Reference(Patient Profile - VN Core R4) The patient or group present at the encounter
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn S 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... 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
.... type Σ 0..* VNCoreCodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period 0..1 Period Period of time during the encounter that the participant participated
.... individual Σ 0..1 Reference(Practitioner | PractitionerRole | RelatedPerson) Persons involved in the encounter other than the patient
... appointment SΣ 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* VNCoreCodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference SΣ 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... Slices for diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
Slice: Unordered, Open by value:use.coding.system, value:use.coding.code
.... diagnosis:All Slices Content/Rules for all slices
..... 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
..... condition Σ 1..1 Reference(Condition - Encounter Diagnosis- VN Core R4) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:AdmissionDiagnosis-CDVaoVien Σ 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: AD
....... display 1..1 string Representation defined by the system
Fixed Value: Admission diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Admission diagnosis
.... diagnosis:DischargeDiagnosis-CDRaVien Σ 0..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: DD
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Discharge diagnosis
.... diagnosis:ChiefComplaint_CDBenhChinh Σ 1..1 BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CC
....... display 1..1 string Representation defined by the system
Fixed Value: Chief complaint
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: Chief complaint
.... diagnosis:ComorbidityDiagnosis-CDBenhPhu Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: CM
....... display 1..1 string Representation defined by the system
Fixed Value: Comorbidity diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:Pre_opDiagnosis_CDTruocPTTT Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pre-op
....... display 1..1 string Representation defined by the system
Fixed Value: pre-op diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: pre-op diagnosis
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
.... diagnosis:Post_opDiagnosis_CDSauPTTT Σ 0..* BackboneElement The list of diagnosis relevant to this encounter
..... 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
..... condition Σ 1..1 Reference(Condition | Procedure) The diagnosis or procedure relevant to the encounter
..... use 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/diagnosis-role
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: post-op
....... display 1..1 string Representation defined by the system
Fixed Value: post-op diagnosis
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 1..1 string Plain text representation of the concept
Fixed Value: post-op diagnosis
..... rank 0..1 positiveInt Ranking of the diagnosis (for each role type)
... account 0..* Reference(Account) The set of accounts that may be used for billing for this Encounter
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... 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
.... preAdmissionIdentifier S 0..1 Identifier Pre-admission identifier
.... origin S 0..1 Reference(Location | Organization) The location/organization from which the patient came before admission
.... admitSource S 0..1 VNCoreCodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 VNCoreCodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dietPreference 0..* VNCoreCodeableConcept Diet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


.... specialCourtesy 0..* VNCoreCodeableConcept Special courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred): Special courtesies.


.... specialArrangement 0..* VNCoreCodeableConcept Wheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred): Special arrangements.


.... destination S 0..1 Reference(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 VNCoreCodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... 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
.... location 1..1 Reference(Location Profile - VN Core R4) Location the encounter takes place
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1 CodeableConcept The physical type of the location (usually the level in the location hierachy - bed room ward etc.)
Binding: LocationType (example): Physical form of the location.

.... period 0..1 Period Time period during which the patient was present at the location
... serviceProvider S 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) The organization (facility) responsible for this encounter
... partOf S 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / CodeURI
Encounter.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.identifier:MaBenhAn.userequiredFixed Value: official
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier:MaBenhAn.typeextensibleFixed Value: MR("Medical record number")
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.identifier:MaDotThamKham.userequiredFixed Value: official
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier:MaDotThamKham.typeextensibleFixed Value: VN("Visit number")
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.identifier:MaLuuTru.userequiredFixed Value: official
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier:MaLuuTru.typeextensibleFixed Value: MR("Medical record number")
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.statusHistory.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typeexampleEncounterType
http://hl7.org/fhir/ValueSet/encounter-type
from the FHIR Standard
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.priorityexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:AdmissionDiagnosis-CDVaoVien.usepreferredPattern: "Admission diagnosis"
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:DischargeDiagnosis-CDRaVien.usepreferredPattern: "Discharge diagnosis"
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:ChiefComplaint_CDBenhChinh.usepreferredPattern: "Chief complaint"
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:ComorbidityDiagnosis-CDBenhPhu.usepreferredPattern: CM("Comorbidity diagnosis")
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:Pre_opDiagnosis_CDTruocPTTT.usepreferredPattern: "pre-op diagnosis"
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.diagnosis:Post_opDiagnosis_CDSauPTTT.usepreferredPattern: "post-op diagnosis"
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dietPreferenceexampleDiet
http://hl7.org/fhir/ValueSet/encounter-diet
from the FHIR Standard
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
http://hl7.org/fhir/ValueSet/encounter-special-courtesy
from the FHIR Standard
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
http://hl7.org/fhir/ValueSet/encounter-special-arrangements
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard
Encounter.location.statusrequiredEncounterLocationStatus
http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1
from the FHIR Standard
Encounter.location.physicalTypeexampleLocationType
http://hl7.org/fhir/ValueSet/location-physical-type
from the FHIR Standard

Constraints

Constraints

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