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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 & Constraintsdoco
.. MedicationAdministration MedicationAdministration
... 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 Concept - reference to a terminology or just text
... 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 Concept - reference to a terminology or just text
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 Concept - reference to a terminology or just text
... 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 Concept - reference to a terminology or just text
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 & Constraintsdoco
.. 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
... 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 Concept - reference to a terminology or just text
Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated.


... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 Concept - reference to a terminology or just text
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
mad-1: SHALL have at least one of dosage.dose or dosage.rate[x]
.... 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 Concept - reference to a terminology or just text
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 & Constraintsdoco
.. MedicationAdministration MedicationAdministration
... 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 Concept - reference to a terminology or just text
... 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 Concept - reference to a terminology or just text
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 Concept - reference to a terminology or just text
... 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 Concept - reference to a terminology or just text
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 & Constraintsdoco
.. 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
... 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 Concept - reference to a terminology or just text
Binding: SNOMEDCTReasonMedicationNotGivenCodes (example): A set of codes indicating the reason why the MedicationAdministration is negated.


... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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 Concept - reference to a terminology or just text
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
mad-1: SHALL have at least one of dosage.dose or dosage.rate[x]
.... 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 Concept - reference to a terminology or just text
Binding: ValueSet dành cho Vị trí cơ thể theo giải phẫu học (SNOMED CT) (preferred)
.... route 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Đường dùng thuốc (SNOMED CT) (preferred)
.... method 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
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

PathConformanceValueSetURI
MedicationAdministration.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
MedicationAdministration.statusrequiredMedicationAdministration Status Codes
http://hl7.org/fhir/ValueSet/medication-admin-status|4.0.1
from the FHIR Standard
MedicationAdministration.statusReasonexampleSNOMEDCTReasonMedicationNotGivenCodes
http://hl7.org/fhir/ValueSet/reason-medication-not-given-codes
from the FHIR Standard
MedicationAdministration.categorypreferredMedicationAdministration Category Codes
http://hl7.org/fhir/ValueSet/medication-admin-category
from the FHIR Standard
MedicationAdministration.medication[x]exampleSNOMEDCTMedicationCodes
http://hl7.org/fhir/ValueSet/medication-codes
from the FHIR Standard
MedicationAdministration.medication[x]:medicationCodeableConceptextensibleValueSet-VN_Core_Medication_Code
http://fhir.ehealth.gov.vn/core/ValueSet/vn-medication-code
from this IG
MedicationAdministration.performer.functionexampleMedicationAdministration Performer Function Codes
http://hl7.org/fhir/ValueSet/med-admin-perform-function
from the FHIR Standard
MedicationAdministration.reasonCodeexampleReasonMedicationGivenCodes
http://hl7.org/fhir/ValueSet/reason-medication-given-codes
from the FHIR Standard
MedicationAdministration.dosage.sitepreferredValueSet-SnomedCT_Anatomical_Body_Structure
http://fhir.ehealth.gov.vn/core/ValueSet/snomedCT-anatomical-body-structure
from this IG
MedicationAdministration.dosage.routepreferredValueSet-SnomedCT_Dosage_Administration_Route
http://fhir.ehealth.gov.vn/core/ValueSet/snomedCT-dosage-administration-route
from this IG
MedicationAdministration.dosage.methodpreferredSNOMEDCTAdministrationMethodCodes
http://hl7.org/fhir/ValueSet/administration-method-codes
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorMedicationAdministrationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorMedicationAdministrationIf 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-4errorMedicationAdministrationIf 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-5errorMedicationAdministrationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceMedicationAdministrationA 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()
mad-1errorMedicationAdministration.dosageSHALL have at least one of dosage.dose or dosage.rate[x]
: dose.exists() or rate.exists()