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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: VNCoreImagingStudy

Thông tin về các file chẩn đoán hình ảnh (X-Quang, chụp CT,…) - được lưu trữ dưới định dạng DICOM

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-imaging-study

Nội dung Profile

Thông tin bổ sung cho các thông tin hiển thị (Nội dung mô tả, Differential Table, Snapshot Table, ...).

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy S 0..* ImagingStudyUvIps A set of images produced in single study (one or more series of references images)
... 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
... identifier SΣ 0..* Identifier Identifiers for the whole study
... status ?!Σ 1..1 code registered | available | cancelled | entered-in-error | unknown
Binding: ImagingStudyStatus (required): The status of the ImagingStudy.

... modality Σ 0..* Coding All series modality if actual acquisition modalities
Binding: AcquisitionModality . (extensible): Type of acquired data in the instance.


... subject SΣ 1..1 Reference(Patient (IPS) | Patient Profile - VN Core R4) Who or what is the subject of the study
.... 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 Σ 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter with which this imaging study is associated
... started SΣ 0..1 dateTime When the study was started
Example General: 2011-01-01T08:01:20+00:00
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | Appointment | AppointmentResponse | Task | ServiceRequest profile - VN Core R4) Request fulfilled
... referrer Σ 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Referring physician
... interpreter Σ 0..* Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who interpreted images
... endpoint Σ 0..* Reference(Endpoint) Study access endpoint
... numberOfSeries SΣ 0..1 unsignedInt Number of Study Related Series
... numberOfInstances SΣ 0..1 unsignedInt Number of Study Related Instances
... procedureReference Σ 0..1 Reference(Procedure | Procedure Profile - VN Core R4) The performed Procedure reference
... procedureCode S 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): The performed procedure type.


... location Σ 0..1 Reference(Location | Location Profile - VN Core R4) Where ImagingStudy occurred
... reasonCode S 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ProcedureReasonCodes (example): The reason for the study.


... reasonReference Σ 0..* Reference(Condition | Observation | Media | DiagnosticReport | DocumentReference | Condition - Encounter Diagnosis- VN Core R4) Why was study performed
... note Σ 0..* Annotation User-defined comments
... description Σ 0..1 string Institution-generated description
... series SΣ 0..* BackboneElement Each study has one or more series of instances
.... 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
.... uid SΣ 1..1 id DICOM Series Instance UID for the series
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... number Σ 0..1 unsignedInt Numeric identifier of this series
Example General: 3
.... modality SΣ 1..1 Coding The modality of the instances in the series
Binding: AcquisitionModality . (extensible): Type of acquired data in the instance.

.... description Σ 0..1 string A short human readable summary of the series
Example General: CT Surview 180
.... numberOfInstances Σ 0..1 unsignedInt Number of Series Related Instances
.... endpoint Σ 0..* Reference(Endpoint) Series access endpoint
.... bodySite Σ 0..1 Coding Body part examined
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

.... laterality Σ 0..1 Coding Body part laterality
Binding: Laterality (example): Codes describing body site laterality (left, right, etc.).

.... specimen Σ 0..* Reference(Specimen) Specimen imaged
.... started Σ 0..1 dateTime When the series started
.... performer Σ 0..* BackboneElement Who performed the series
..... 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
..... function Σ 0..1 CodeableConcept Type of performance
Binding: ImagingStudySeriesPerformerFunction (extensible): The type of involvement of the performer.

..... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | Device | RelatedPerson) Who performed the series
.... instance S 0..* BackboneElement A single SOP instance from the series
..... 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
..... uid S 1..1 id DICOM SOP Instance UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class type
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): The sopClass for the instance.

..... number 0..1 unsignedInt The number of this instance in the series
Example General: 1
..... title 0..1 string Description of instance

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ImagingStudy S 0..* ImagingStudyUvIps A set of images produced in single study (one or more series of references images)
... 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
... identifier SΣ 0..* Identifier Identifiers for the whole study
... status ?!Σ 1..1 code registered | available | cancelled | entered-in-error | unknown
Binding: ImagingStudyStatus (required): The status of the ImagingStudy.

... modality Σ 0..* Coding All series modality if actual acquisition modalities
Binding: AcquisitionModality . (extensible): Type of acquired data in the instance.


... subject SΣ 1..1 Reference(Patient (IPS) | Patient Profile - VN Core R4) Who or what is the subject of the study
.... 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 Σ 0..1 Reference(Encounter | Encounter Profile - VN Core R4) Encounter with which this imaging study is associated
... started SΣ 0..1 dateTime When the study was started
Example General: 2011-01-01T08:01:20+00:00
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | Appointment | AppointmentResponse | Task | ServiceRequest profile - VN Core R4) Request fulfilled
... referrer Σ 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Referring physician
... interpreter Σ 0..* Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who interpreted images
... endpoint Σ 0..* Reference(Endpoint) Study access endpoint
... numberOfSeries SΣ 0..1 unsignedInt Number of Study Related Series
... numberOfInstances SΣ 0..1 unsignedInt Number of Study Related Instances
... procedureReference Σ 0..1 Reference(Procedure | Procedure Profile - VN Core R4) The performed Procedure reference
... procedureCode S 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: http://www.rsna.org/RadLex_Playbook.aspx (extensible): The performed procedure type.


... location Σ 0..1 Reference(Location | Location Profile - VN Core R4) Where ImagingStudy occurred
... reasonCode S 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ProcedureReasonCodes (example): The reason for the study.


... reasonReference Σ 0..* Reference(Condition | Observation | Media | DiagnosticReport | DocumentReference | Condition - Encounter Diagnosis- VN Core R4) Why was study performed
... note Σ 0..* Annotation User-defined comments
... description Σ 0..1 string Institution-generated description
... series SΣ 0..* BackboneElement Each study has one or more series of instances
.... 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
.... uid SΣ 1..1 id DICOM Series Instance UID for the series
Example General: 2.16.124.113543.6003.2588828330.45298.17418.2723805630
.... number Σ 0..1 unsignedInt Numeric identifier of this series
Example General: 3
.... modality SΣ 1..1 Coding The modality of the instances in the series
Binding: AcquisitionModality . (extensible): Type of acquired data in the instance.

.... description Σ 0..1 string A short human readable summary of the series
Example General: CT Surview 180
.... numberOfInstances Σ 0..1 unsignedInt Number of Series Related Instances
.... endpoint Σ 0..* Reference(Endpoint) Series access endpoint
.... bodySite Σ 0..1 Coding Body part examined
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

.... laterality Σ 0..1 Coding Body part laterality
Binding: Laterality (example): Codes describing body site laterality (left, right, etc.).

.... specimen Σ 0..* Reference(Specimen) Specimen imaged
.... started Σ 0..1 dateTime When the series started
.... performer Σ 0..* BackboneElement Who performed the series
..... 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
..... function Σ 0..1 CodeableConcept Type of performance
Binding: ImagingStudySeriesPerformerFunction (extensible): The type of involvement of the performer.

..... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | Device | RelatedPerson) Who performed the series
.... instance S 0..* BackboneElement A single SOP instance from the series
..... 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
..... uid S 1..1 id DICOM SOP Instance UID
Example General: 2.16.124.113543.6003.189642796.63084.16748.2599092903
..... sopClass S 1..1 Coding DICOM class type
Binding: http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1 (extensible): The sopClass for the instance.

..... number 0..1 unsignedInt The number of this instance in the series
Example General: 1
..... title 0..1 string Description of instance

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSetURI
ImagingStudy.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ImagingStudy.statusrequiredImagingStudyStatus
http://hl7.org/fhir/ValueSet/imagingstudy-status|4.0.1
from the FHIR Standard
ImagingStudy.modalityextensibleAcquisitionModality .
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
ImagingStudy.procedureCodeextensiblehttp://www.rsna.org/RadLex_Playbook.aspx
http://www.rsna.org/RadLex_Playbook.aspx
ImagingStudy.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
ImagingStudy.series.modalityextensibleAcquisitionModality .
http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_29.html
ImagingStudy.series.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
ImagingStudy.series.lateralityexampleLaterality
http://hl7.org/fhir/ValueSet/bodysite-laterality
from the FHIR Standard
ImagingStudy.series.performer.functionextensibleImagingStudySeriesPerformerFunction
http://hl7.org/fhir/ValueSet/series-performer-function
from the FHIR Standard
ImagingStudy.series.instance.sopClassextensiblehttp://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1
http://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

Constraints

Constraints

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