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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: VNCoreMedicationRequest

Thông tin về chỉ định/y lệnh Dược tại Cơ sở khám, chữa 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-request

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 MedicationRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationRequest MedicationRequest
... identifier S 0..* Identifier External ids for this request
... statusReason 0..1 VNCoreCodeableConcept Reason for current status
... category S 0..* VNCoreCodeableConcept Type of medication usage
... Slices for medicationCodeableConcept Content/Rules for all slices
.... medicationCodeableConcept:medicationCodeableConcept 0..1 VNCoreCodeableConcept Medication to be taken
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) Medication to be taken
... subject 1..1 Reference(Patient Profile - VN Core R4) Who or group medication request is for
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of encounter/admission/stay
... authoredOn S 0..1 dateTime When request was initially authored
... requester S 1..1 Reference(Practitioner Profile - VN Core R4) Who/What requested the Request
... performer 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson | CareTeam | Practitioner Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Intended performer of administration
... performerType S 0..1 CodeableConcept Desired kind of performer of the medication administration
... recorder S 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who entered the request
... reasonCode S 0..* VNCoreCodeableConcept Reason or indication for ordering or not ordering the medication
... basedOn S 0..* Reference(CarePlan | MedicationRequest | ServiceRequest | ImmunizationRecommendation | MedicationRequest Profile - VN Core R4) What request fulfills
... groupIdentifier S 0..1 Identifier Composite request this is part of
... note S 0..* Annotation Information about the prescription
... dosageInstruction S 0..* VNCoreDosage How the medication should be taken
... dispenseRequest S 0..1 BackboneElement Medication supply authorization

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationRequest 0..* MedicationRequest Ordering of medication for patient or group
... 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 ids for this request
... status ?!Σ 1..1 code active | on-hold | cancelled | completed | entered-in-error | stopped | draft | unknown
Binding: medicationrequest Status (required): A coded concept specifying the state of the prescribing event. Describes the lifecycle of the prescription.

... statusReason 0..1 VNCoreCodeableConcept Reason for current status
Binding: medicationRequest Status Reason Codes (example): Identifies the reasons for a given status.

... intent ?!Σ 1..1 code proposal | plan | order | original-order | reflex-order | filler-order | instance-order | option
Binding: medicationRequest Intent (required): The kind of medication order.

... category S 0..* VNCoreCodeableConcept Type of medication usage
Binding: medicationRequest Category Codes (example): A coded concept identifying the category of medication request. For example, where the medication is to be consumed or administered, or the type of medication treatment.


... priority Σ 0..1 code routine | urgent | asap | stat
Binding: RequestPriority (required): Identifies the level of importance to be assigned to actioning the request.

... doNotPerform ?!Σ 0..1 boolean True if request is prohibiting action
... reported[x] Σ 0..1 Reported rather than primary record
.... reportedBoolean boolean
.... reportedReference Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization)
... Slices for medication[x] Σ 1..1 Medication to be taken
Slice: Unordered, Closed by type:$this
Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying substance or product that can be ordered.

.... medicationCodeableConcept CodeableConcept
.... medicationReference Reference(Medication)
.... medication[x]:medicationCodeableConcept Σ 0..1 VNCoreCodeableConcept Medication to be taken
Binding: ValueSet dành cho Mã dược phẩm (extensible)
.... medication[x]:medicationReference Σ 0..1 Reference(Medication | Medication Profile - VN Core R4) Medication to be taken
... subject Σ 1..1 Reference(Patient Profile - VN Core R4) Who or group medication request is for
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of encounter/admission/stay
... supportingInformation 0..* Reference(Resource) Information to support ordering of the medication
... authoredOn SΣ 0..1 dateTime When request was initially authored
... requester SΣ 1..1 Reference(Practitioner Profile - VN Core R4) Who/What requested the Request
... performer 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson | CareTeam | Practitioner Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Intended performer of administration
... performerType SΣ 0..1 CodeableConcept Desired kind of performer of the medication administration
Binding: ProcedurePerformerRoleCodes (example): Identifies the type of individual that is desired to administer the medication.

... recorder S 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who entered the request
... reasonCode S 0..* VNCoreCodeableConcept Reason or indication for ordering or not ordering the medication
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept indicating why the medication was ordered.


... reasonReference 0..* Reference(Condition | Observation) Condition or observation that supports why the prescription is being written
... instantiatesCanonical Σ 0..* canonical() Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn SΣ 0..* Reference(CarePlan | MedicationRequest | ServiceRequest | ImmunizationRecommendation | MedicationRequest Profile - VN Core R4) What request fulfills
... groupIdentifier SΣ 0..1 Identifier Composite request this is part of
... courseOfTherapyType 0..1 CodeableConcept Overall pattern of medication administration
Binding: medicationRequest Course of Therapy Codes (example): Identifies the overall pattern of medication administratio.

... insurance 0..* Reference(Coverage | ClaimResponse) Associated insurance coverage
... note S 0..* Annotation Information about the prescription
... dosageInstruction S 0..* VNCoreDosage How the medication should be taken
... dispenseRequest S 0..1 BackboneElement Medication supply authorization
.... 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
.... initialFill 0..1 BackboneElement First fill details
..... 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
..... quantity 0..1 SimpleQuantity First fill quantity
..... duration 0..1 Duration First fill duration
.... dispenseInterval 0..1 Duration Minimum period of time between dispenses
.... validityPeriod 0..1 Period Time period supply is authorized for
.... numberOfRepeatsAllowed 0..1 unsignedInt Number of refills authorized
.... quantity 0..1 SimpleQuantity Amount of medication to supply per dispense
.... expectedSupplyDuration 0..1 Duration Number of days supply per dispense
.... performer 0..1 Reference(Organization) Intended dispenser
... substitution 0..1 BackboneElement Any restrictions on medication substitution
.... 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
.... allowed[x] 1..1 Whether substitution is allowed or not
Binding: ActSubstanceAdminSubstitutionCode (example): Identifies the type of substitution allowed.

..... allowedBoolean boolean
..... allowedCodeableConcept CodeableConcept
.... reason 0..1 CodeableConcept Why should (not) substitution be made
Binding: SubstanceAdminSubstitutionReason (example): A coded concept describing the reason that a different medication should (or should not) be substituted from what was prescribed.

... priorPrescription 0..1 Reference(MedicationRequest) An order/prescription that is being replaced
... detectedIssue 0..* Reference(DetectedIssue) Clinical Issue with action
... 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 MedicationRequest

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationRequest MedicationRequest
... identifier S 0..* Identifier External ids for this request
... statusReason 0..1 VNCoreCodeableConcept Reason for current status
... category S 0..* VNCoreCodeableConcept Type of medication usage
... Slices for medicationCodeableConcept Content/Rules for all slices
.... medicationCodeableConcept:medicationCodeableConcept 0..1 VNCoreCodeableConcept Medication to be taken
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) Medication to be taken
... subject 1..1 Reference(Patient Profile - VN Core R4) Who or group medication request is for
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of encounter/admission/stay
... authoredOn S 0..1 dateTime When request was initially authored
... requester S 1..1 Reference(Practitioner Profile - VN Core R4) Who/What requested the Request
... performer 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson | CareTeam | Practitioner Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Intended performer of administration
... performerType S 0..1 CodeableConcept Desired kind of performer of the medication administration
... recorder S 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who entered the request
... reasonCode S 0..* VNCoreCodeableConcept Reason or indication for ordering or not ordering the medication
... basedOn S 0..* Reference(CarePlan | MedicationRequest | ServiceRequest | ImmunizationRecommendation | MedicationRequest Profile - VN Core R4) What request fulfills
... groupIdentifier S 0..1 Identifier Composite request this is part of
... note S 0..* Annotation Information about the prescription
... dosageInstruction S 0..* VNCoreDosage How the medication should be taken
... dispenseRequest S 0..1 BackboneElement Medication supply authorization

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationRequest 0..* MedicationRequest Ordering of medication for patient or group
... 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 ids for this request
... status ?!Σ 1..1 code active | on-hold | cancelled | completed | entered-in-error | stopped | draft | unknown
Binding: medicationrequest Status (required): A coded concept specifying the state of the prescribing event. Describes the lifecycle of the prescription.

... statusReason 0..1 VNCoreCodeableConcept Reason for current status
Binding: medicationRequest Status Reason Codes (example): Identifies the reasons for a given status.

... intent ?!Σ 1..1 code proposal | plan | order | original-order | reflex-order | filler-order | instance-order | option
Binding: medicationRequest Intent (required): The kind of medication order.

... category S 0..* VNCoreCodeableConcept Type of medication usage
Binding: medicationRequest Category Codes (example): A coded concept identifying the category of medication request. For example, where the medication is to be consumed or administered, or the type of medication treatment.


... priority Σ 0..1 code routine | urgent | asap | stat
Binding: RequestPriority (required): Identifies the level of importance to be assigned to actioning the request.

... doNotPerform ?!Σ 0..1 boolean True if request is prohibiting action
... reported[x] Σ 0..1 Reported rather than primary record
.... reportedBoolean boolean
.... reportedReference Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization)
... Slices for medication[x] Σ 1..1 Medication to be taken
Slice: Unordered, Closed by type:$this
Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying substance or product that can be ordered.

.... medicationCodeableConcept CodeableConcept
.... medicationReference Reference(Medication)
.... medication[x]:medicationCodeableConcept Σ 0..1 VNCoreCodeableConcept Medication to be taken
Binding: ValueSet dành cho Mã dược phẩm (extensible)
.... medication[x]:medicationReference Σ 0..1 Reference(Medication | Medication Profile - VN Core R4) Medication to be taken
... subject Σ 1..1 Reference(Patient Profile - VN Core R4) Who or group medication request is for
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of encounter/admission/stay
... supportingInformation 0..* Reference(Resource) Information to support ordering of the medication
... authoredOn SΣ 0..1 dateTime When request was initially authored
... requester SΣ 1..1 Reference(Practitioner Profile - VN Core R4) Who/What requested the Request
... performer 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson | CareTeam | Practitioner Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Intended performer of administration
... performerType SΣ 0..1 CodeableConcept Desired kind of performer of the medication administration
Binding: ProcedurePerformerRoleCodes (example): Identifies the type of individual that is desired to administer the medication.

... recorder S 0..1 Reference(Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who entered the request
... reasonCode S 0..* VNCoreCodeableConcept Reason or indication for ordering or not ordering the medication
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept indicating why the medication was ordered.


... reasonReference 0..* Reference(Condition | Observation) Condition or observation that supports why the prescription is being written
... instantiatesCanonical Σ 0..* canonical() Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn SΣ 0..* Reference(CarePlan | MedicationRequest | ServiceRequest | ImmunizationRecommendation | MedicationRequest Profile - VN Core R4) What request fulfills
... groupIdentifier SΣ 0..1 Identifier Composite request this is part of
... courseOfTherapyType 0..1 CodeableConcept Overall pattern of medication administration
Binding: medicationRequest Course of Therapy Codes (example): Identifies the overall pattern of medication administratio.

... insurance 0..* Reference(Coverage | ClaimResponse) Associated insurance coverage
... note S 0..* Annotation Information about the prescription
... dosageInstruction S 0..* VNCoreDosage How the medication should be taken
... dispenseRequest S 0..1 BackboneElement Medication supply authorization
.... 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
.... initialFill 0..1 BackboneElement First fill details
..... 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
..... quantity 0..1 SimpleQuantity First fill quantity
..... duration 0..1 Duration First fill duration
.... dispenseInterval 0..1 Duration Minimum period of time between dispenses
.... validityPeriod 0..1 Period Time period supply is authorized for
.... numberOfRepeatsAllowed 0..1 unsignedInt Number of refills authorized
.... quantity 0..1 SimpleQuantity Amount of medication to supply per dispense
.... expectedSupplyDuration 0..1 Duration Number of days supply per dispense
.... performer 0..1 Reference(Organization) Intended dispenser
... substitution 0..1 BackboneElement Any restrictions on medication substitution
.... 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
.... allowed[x] 1..1 Whether substitution is allowed or not
Binding: ActSubstanceAdminSubstitutionCode (example): Identifies the type of substitution allowed.

..... allowedBoolean boolean
..... allowedCodeableConcept CodeableConcept
.... reason 0..1 CodeableConcept Why should (not) substitution be made
Binding: SubstanceAdminSubstitutionReason (example): A coded concept describing the reason that a different medication should (or should not) be substituted from what was prescribed.

... priorPrescription 0..1 Reference(MedicationRequest) An order/prescription that is being replaced
... detectedIssue 0..* Reference(DetectedIssue) Clinical Issue with action
... 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
MedicationRequest.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
MedicationRequest.statusrequiredmedicationrequest Status
http://hl7.org/fhir/ValueSet/medicationrequest-status|4.0.1
from the FHIR Standard
MedicationRequest.statusReasonexamplemedicationRequest Status Reason Codes
http://hl7.org/fhir/ValueSet/medicationrequest-status-reason
from the FHIR Standard
MedicationRequest.intentrequiredmedicationRequest Intent
http://hl7.org/fhir/ValueSet/medicationrequest-intent|4.0.1
from the FHIR Standard
MedicationRequest.categoryexamplemedicationRequest Category Codes
http://hl7.org/fhir/ValueSet/medicationrequest-category
from the FHIR Standard
MedicationRequest.priorityrequiredRequestPriority
http://hl7.org/fhir/ValueSet/request-priority|4.0.1
from the FHIR Standard
MedicationRequest.medication[x]exampleSNOMEDCTMedicationCodes
http://hl7.org/fhir/ValueSet/medication-codes
from the FHIR Standard
MedicationRequest.medication[x]:medicationCodeableConceptextensibleValueSet-VN_Core_Medication_Code
http://fhir.ehealth.gov.vn/core/ValueSet/vn-medication-code
from this IG
MedicationRequest.performerTypeexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
MedicationRequest.reasonCodeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
MedicationRequest.courseOfTherapyTypeexamplemedicationRequest Course of Therapy Codes
http://hl7.org/fhir/ValueSet/medicationrequest-course-of-therapy
from the FHIR Standard
MedicationRequest.substitution.allowed[x]exampleActSubstanceAdminSubstitutionCode
http://terminology.hl7.org/ValueSet/v3-ActSubstanceAdminSubstitutionCode
MedicationRequest.substitution.reasonexampleSubstanceAdminSubstitutionReason
http://terminology.hl7.org/ValueSet/v3-SubstanceAdminSubstitutionReason

Constraints

Constraints

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