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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: VNCoreMedicationAdministration

Thông tin mô tả liên quan đến quá trình sử dụng thuốc của người bệnh. Tham khảo thêm: https://www.hl7.org/fhir/medications-module.html

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-medication-administration

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 MedicationAdministration

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationAdministration 0..* MedicationAdministration Administration of medication to a patient
... identifier S 0..* Identifier External identifier
... partOf S 0..* Reference(MedicationAdministration | Procedure | MedicationAdministration Profile - VN Core R4 | Procedure Profile - VN Core R4) Part of referenced event
... statusReason S 0..* VNCoreCodeableConcept Reason administration not performed
... medication[x] S 1..1 CodeableConcept, Reference(Medication) What was administered
Slice: Unordered, Open by type:$this
... Slices for medicationCodeableConcept Content/Rules for all slices
.... medicationCodeableConcept:medicationCodeableConcept 0..1 VNCoreCodeableConcept What was administered
Binding: ValueSet dành cho Mã dược phẩm (extensible)
... Slices for medicationReference Content/Rules for all slices
.... medicationReference:medicationReference 0..1 Reference(Medication | Medication Profile - VN Core R4) What was administered
... subject S 1..1 Reference(Patient Profile - VN Core R4) Who received medication
... context S 0..1 Reference(Encounter Profile - VN Core R4) Encounter or Episode of Care administered as part of
... effective[x] S 1..1 dateTime, Period Start and end time of administration
... performer S 0..* BackboneElement Who performed the medication administration and what they did
.... actor 1..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Practitioner Profile - VN Core R4) Who performed the medication administration
... reasonCode S 0..* VNCoreCodeableConcept Reason administration performed
... reasonReference S 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication was administered
... request S 0..1 Reference(MedicationRequest Profile - VN Core R4) Request administration performed against
... device S 0..* Reference(Device) Device used to administer
... note S 0..* Annotation Information about the administration
... dosage S 0..1 BackboneElement Details of how medication was taken
.... text 1..1 string Free text dosage instructions e.g. SIG
.... site 0..1 VNCoreCodeableConcept Body site administered to
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Path of substance into body
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept How drug was administered
Binding: SNOMEDCTAdministrationMethodCodes (preferred)
.... dose 0..1 SimpleQuantity, SimpleQuantityIPS Amount of medication per dose
.... rate[x] 0..1 Dose quantity per unit of time
..... rateRatio Ratio(RatioIPS)
..... rateQuantity Quantity(SimpleQuantity | SimpleQuantityIPS)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationAdministration 0..* MedicationAdministration Administration of medication to a 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier External identifier
... instantiates Σ 0..* uri Instantiates protocol or definition
... partOf SΣ 0..* Reference(MedicationAdministration | Procedure | MedicationAdministration Profile - VN Core R4 | Procedure Profile - VN Core R4) Part of referenced event
... status ?!Σ 1..1 code in-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown
Binding: MedicationAdministration Status Codes (required): A set of codes indicating the current status of a MedicationAdministration.
... statusReason S 0..* VNCoreCodeableConcept Reason administration not performed
Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated.
... category S 0..1 VNCoreCodeableConcept Type of medication usage
Binding: MedicationAdministration Category Codes (preferred): A coded concept describing where the medication administered is expected to occur.
... Slices for medication[x] SΣ 1..1 What was administered
Slice: Unordered, Closed by type:$this
Binding: SNOMEDCTMedicationCodes (example): Codes identifying substance or product that can be administered.
.... medicationCodeableConcept CodeableConcept
.... medicationReference Reference(Medication)
.... medication[x]:medicationCodeableConcept Σ 0..1 VNCoreCodeableConcept What was administered
Binding: ValueSet dành cho Mã dược phẩm (extensible)
.... medication[x]:medicationReference Σ 0..1 Reference(Medication | Medication Profile - VN Core R4) What was administered
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who received medication
... context S 0..1 Reference(Encounter Profile - VN Core R4) Encounter or Episode of Care administered as part of
... supportingInformation 0..* Reference(Resource) Additional information to support administration
... effective[x] SΣ 1..1 Start and end time of administration
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* BackboneElement Who performed the medication administration and what they did
.... 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 0..1 CodeableConcept Type of performance
Binding: MedicationAdministration Performer Function Codes (example): A code describing the role an individual played in administering the medication.
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Practitioner Profile - VN Core R4) Who performed the medication administration
... reasonCode S 0..* VNCoreCodeableConcept Reason administration performed
Binding: ReasonMedicationGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration was made.
... reasonReference S 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication was administered
... request S 0..1 Reference(MedicationRequest Profile - VN Core R4) Request administration performed against
... device S 0..* Reference(Device) Device used to administer
... note S 0..* Annotation Information about the administration
... dosage SC 0..1 BackboneElement Details of how medication was taken
Constraints: mad-1
.... 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
.... text 1..1 string Free text dosage instructions e.g. SIG
.... site 0..1 VNCoreCodeableConcept Body site administered to
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Path of substance into body
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept How drug was administered
Binding: SNOMEDCTAdministrationMethodCodes (preferred)
.... dose 0..1 SimpleQuantity, SimpleQuantityIPS Amount of medication per dose
.... rate[x] 0..1 Dose quantity per unit of time
..... rateRatio Ratio(RatioIPS)
..... rateQuantity Quantity(SimpleQuantity | SimpleQuantityIPS)
... eventHistory 0..* Reference(Provenance) A list of events of interest in the lifecycle

doco Documentation for this format

Differential View

Profile này được dựa trên Resource MedicationAdministration

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationAdministration 0..* MedicationAdministration Administration of medication to a patient
... identifier S 0..* Identifier External identifier
... partOf S 0..* Reference(MedicationAdministration | Procedure | MedicationAdministration Profile - VN Core R4 | Procedure Profile - VN Core R4) Part of referenced event
... statusReason S 0..* VNCoreCodeableConcept Reason administration not performed
... medication[x] S 1..1 CodeableConcept, Reference(Medication) What was administered
Slice: Unordered, Open by type:$this
... Slices for medicationCodeableConcept Content/Rules for all slices
.... medicationCodeableConcept:medicationCodeableConcept 0..1 VNCoreCodeableConcept What was administered
Binding: ValueSet dành cho Mã dược phẩm (extensible)
... Slices for medicationReference Content/Rules for all slices
.... medicationReference:medicationReference 0..1 Reference(Medication | Medication Profile - VN Core R4) What was administered
... subject S 1..1 Reference(Patient Profile - VN Core R4) Who received medication
... context S 0..1 Reference(Encounter Profile - VN Core R4) Encounter or Episode of Care administered as part of
... effective[x] S 1..1 dateTime, Period Start and end time of administration
... performer S 0..* BackboneElement Who performed the medication administration and what they did
.... actor 1..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Practitioner Profile - VN Core R4) Who performed the medication administration
... reasonCode S 0..* VNCoreCodeableConcept Reason administration performed
... reasonReference S 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication was administered
... request S 0..1 Reference(MedicationRequest Profile - VN Core R4) Request administration performed against
... device S 0..* Reference(Device) Device used to administer
... note S 0..* Annotation Information about the administration
... dosage S 0..1 BackboneElement Details of how medication was taken
.... text 1..1 string Free text dosage instructions e.g. SIG
.... site 0..1 VNCoreCodeableConcept Body site administered to
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Path of substance into body
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept How drug was administered
Binding: SNOMEDCTAdministrationMethodCodes (preferred)
.... dose 0..1 SimpleQuantity, SimpleQuantityIPS Amount of medication per dose
.... rate[x] 0..1 Dose quantity per unit of time
..... rateRatio Ratio(RatioIPS)
..... rateQuantity Quantity(SimpleQuantity | SimpleQuantityIPS)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. MedicationAdministration 0..* MedicationAdministration Administration of medication to a 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 0..* Identifier External identifier
... instantiates Σ 0..* uri Instantiates protocol or definition
... partOf SΣ 0..* Reference(MedicationAdministration | Procedure | MedicationAdministration Profile - VN Core R4 | Procedure Profile - VN Core R4) Part of referenced event
... status ?!Σ 1..1 code in-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown
Binding: MedicationAdministration Status Codes (required): A set of codes indicating the current status of a MedicationAdministration.
... statusReason S 0..* VNCoreCodeableConcept Reason administration not performed
Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated.
... category S 0..1 VNCoreCodeableConcept Type of medication usage
Binding: MedicationAdministration Category Codes (preferred): A coded concept describing where the medication administered is expected to occur.
... Slices for medication[x] SΣ 1..1 What was administered
Slice: Unordered, Closed by type:$this
Binding: SNOMEDCTMedicationCodes (example): Codes identifying substance or product that can be administered.
.... medicationCodeableConcept CodeableConcept
.... medicationReference Reference(Medication)
.... medication[x]:medicationCodeableConcept Σ 0..1 VNCoreCodeableConcept What was administered
Binding: ValueSet dành cho Mã dược phẩm (extensible)
.... medication[x]:medicationReference Σ 0..1 Reference(Medication | Medication Profile - VN Core R4) What was administered
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who received medication
... context S 0..1 Reference(Encounter Profile - VN Core R4) Encounter or Episode of Care administered as part of
... supportingInformation 0..* Reference(Resource) Additional information to support administration
... effective[x] SΣ 1..1 Start and end time of administration
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* BackboneElement Who performed the medication administration and what they did
.... 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 0..1 CodeableConcept Type of performance
Binding: MedicationAdministration Performer Function Codes (example): A code describing the role an individual played in administering the medication.
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Practitioner Profile - VN Core R4) Who performed the medication administration
... reasonCode S 0..* VNCoreCodeableConcept Reason administration performed
Binding: ReasonMedicationGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration was made.
... reasonReference S 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication was administered
... request S 0..1 Reference(MedicationRequest Profile - VN Core R4) Request administration performed against
... device S 0..* Reference(Device) Device used to administer
... note S 0..* Annotation Information about the administration
... dosage SC 0..1 BackboneElement Details of how medication was taken
Constraints: mad-1
.... 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
.... text 1..1 string Free text dosage instructions e.g. SIG
.... site 0..1 VNCoreCodeableConcept Body site administered to
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Path of substance into body
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept How drug was administered
Binding: SNOMEDCTAdministrationMethodCodes (preferred)
.... dose 0..1 SimpleQuantity, SimpleQuantityIPS Amount of medication per dose
.... rate[x] 0..1 Dose quantity per unit of time
..... rateRatio Ratio(RatioIPS)
..... rateQuantity Quantity(SimpleQuantity | SimpleQuantityIPS)
... eventHistory 0..* Reference(Provenance) A list of events of interest in the lifecycle

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

Path Status Usage ValueSet Version Source
MedicationAdministration.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
MedicationAdministration.​status Base required Medication administration status codes 📍4.0.1 FHIR Std.
MedicationAdministration.​statusReason Base example SNOMED CT Reason Medication Not Given Codes 📍4.0.1 FHIR Std.
MedicationAdministration.​category Base preferred Medication administration category codes 📍4.0.1 FHIR Std.
MedicationAdministration.​medication[x] Base example SNOMED CT Medication Codes 📍4.0.1 FHIR Std.
MedicationAdministration.​medication[x]:medicationCodeableConcept Base extensible ValueSet dành cho Mã dược phẩm 📦1.0.0 This IG
MedicationAdministration.​performer.function Base example Medication administration performer function codes 📍4.0.1 FHIR Std.
MedicationAdministration.​reasonCode Base example Reason Medication Given Codes 📍4.0.1 FHIR Std.
MedicationAdministration.​dosage.site Base preferred ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) 📦1.0.0 This IG
MedicationAdministration.​dosage.route Base preferred ValueSet dành cho Đường dùng thuốc (SNOMED CT) 📦1.0.0 This IG
MedicationAdministration.​dosage.method Base preferred SNOMED CT Administration Method Codes 📍4.0.1 FHIR Std.

Constraints

Constraints

Id Grade Path(s) Description Expression
dom-2 error MedicationAdministration If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error MedicationAdministration If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error MedicationAdministration If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error MedicationAdministration If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice MedicationAdministration A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
mad-1 error MedicationAdministration.dosage SHALL have at least one of dosage.dose or dosage.rate[x] dose.exists() or rate.exists()