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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: MedicationStatement

Thông tin đánh giá 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-statement

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 MedicationStatementIPS

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement MedicationStatementIPS
... identifier S 0..* Identifier External identifier
... basedOn 1..* Reference(MedicationRequest | CarePlan | ServiceRequest | MedicationRequest Profile - VN Core R4) Fulfils plan, proposal or order
... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... medicationReference:medicationReference 0..1 Reference(Medication Profile - VN Core R4) What medication was taken
... 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)
... subject 1..1 Reference(Patient Profile - VN Core R4) Who is/was taking the medication
... context 0..1 Reference(Encounter Profile - VN Core R4) Encounter / Episode associated with MedicationStatement
... derivedFrom S 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
... note S 0..* Annotation Further information about the statement
... dosage 0..* VNCoreDosage How the medication is/was taken or should be taken

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement S 0..* MedicationStatementIPS Record of medication being taken by 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
... 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 External identifier
... basedOn Σ 1..* Reference(MedicationRequest | CarePlan | ServiceRequest | MedicationRequest Profile - VN Core R4) Fulfils plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) Part of referenced event
... status ?!SΣ 1..1 code active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.

... statusReason 0..* CodeableConcept Reason for current status
Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.


... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.

... Slices for medication[x] SΣ 1..1 What medication was taken
Slice: Unordered, Closed by type:$this
Binding: Medications (example) - IPS (example): The type of medication

.... medicationReference Reference(Any)
.... medicationCodeableConcept CodeableConcept
.... medication[x]:medicationReference SΣ 0..1 Reference(Medication Profile - VN Core R4) What medication was taken
.... medication[x]:medicationCodeableConcept S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã dược phẩm (extensible)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who is/was taking the medication
.... 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
... context Σ 0..1 Reference(Encounter Profile - VN Core R4) Encounter / Episode associated with MedicationStatement
... effective[x] SΣ 1..1 The date/time or interval when the medication is/was/will be taken
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dateAsserted Σ 0..1 dateTime When the statement was asserted?
... informationSource S 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) Person or organization that provided the information about the taking of this medication
... derivedFrom S 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.


... reasonReference 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication is being/was taken
... note S 0..* Annotation Further information about the statement
... dosage S 0..* VNCoreDosage How the medication is/was taken or should be taken
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 0..1 integer The order of the dosage instructions
.... text SΣ 0..1 string Free text dosage instructions e.g. SIG
.... additionalInstruction Σ 0..* CodeableConcept Supplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness"
Binding: SNOMEDCTAdditionalDosageInstructions (example): A coded concept identifying additional instructions such as "take with water" or "avoid operating heavy machinery".


.... patientInstruction Σ 0..1 string Patient or consumer oriented instructions
.... timing SΣ 0..1 Timing When medication should be administered
.... asNeeded[x] Σ 0..1 Take "as needed" (for x)
Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.

..... asNeededBoolean boolean
..... asNeededCodeableConcept CodeableConcept
.... site Σ 0..1 CodeableConcept Body site to administer to
Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body.

.... route S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Medicine Route of Administration - IPS (preferred): EDQM Standards Terms

.... method Σ 0..1 CodeableConcept Technique for administering medication
Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered.

.... doseAndRate Σ 0..* Element Amount of medication administered
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... type Σ 0..1 CodeableConcept The kind of dose or rate specified
Binding: DoseAndRateType (example): The kind of dose or rate specified.

..... dose[x] Σ 0..1 Amount of medication per dose
...... doseRange Range
...... doseQuantity Quantity(SimpleQuantity)
..... rate[x] Σ 0..1 Amount of medication per unit of time
...... rateRatio Ratio
...... rateRange Range
...... rateQuantity Quantity(SimpleQuantity)
.... maxDosePerPeriod Σ 0..1 Ratio Upper limit on medication per unit of time
.... maxDosePerAdministration Σ 0..1 SimpleQuantity Upper limit on medication per administration
.... maxDosePerLifetime Σ 0..1 SimpleQuantity Upper limit on medication per lifetime of the patient

doco Documentation for this format

Differential View

Profile này được dựa trên Resource MedicationStatementIPS

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement MedicationStatementIPS
... identifier S 0..* Identifier External identifier
... basedOn 1..* Reference(MedicationRequest | CarePlan | ServiceRequest | MedicationRequest Profile - VN Core R4) Fulfils plan, proposal or order
... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
.... medicationReference:medicationReference 0..1 Reference(Medication Profile - VN Core R4) What medication was taken
... 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)
... subject 1..1 Reference(Patient Profile - VN Core R4) Who is/was taking the medication
... context 0..1 Reference(Encounter Profile - VN Core R4) Encounter / Episode associated with MedicationStatement
... derivedFrom S 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
... note S 0..* Annotation Further information about the statement
... dosage 0..* VNCoreDosage How the medication is/was taken or should be taken

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement S 0..* MedicationStatementIPS Record of medication being taken by 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
... 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 External identifier
... basedOn Σ 1..* Reference(MedicationRequest | CarePlan | ServiceRequest | MedicationRequest Profile - VN Core R4) Fulfils plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) Part of referenced event
... status ?!SΣ 1..1 code active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken
Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement.

... statusReason 0..* CodeableConcept Reason for current status
Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement.


... category S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered.

... Slices for medication[x] SΣ 1..1 What medication was taken
Slice: Unordered, Closed by type:$this
Binding: Medications (example) - IPS (example): The type of medication

.... medicationReference Reference(Any)
.... medicationCodeableConcept CodeableConcept
.... medication[x]:medicationReference SΣ 0..1 Reference(Medication Profile - VN Core R4) What medication was taken
.... medication[x]:medicationCodeableConcept S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ValueSet dành cho Mã dược phẩm (extensible)
... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who is/was taking the medication
.... 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
... context Σ 0..1 Reference(Encounter Profile - VN Core R4) Encounter / Episode associated with MedicationStatement
... effective[x] SΣ 1..1 The date/time or interval when the medication is/was/will be taken
.... effective[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... dateAsserted Σ 0..1 dateTime When the statement was asserted?
... informationSource S 0..1 Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) Person or organization that provided the information about the taking of this medication
... derivedFrom S 0..* Reference(Resource) Additional supporting information
... reasonCode 0..* VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken.


... reasonReference 0..* Reference(Condition | Observation | DiagnosticReport) Condition or observation that supports why the medication is being/was taken
... note S 0..* Annotation Further information about the statement
... dosage S 0..* VNCoreDosage How the medication is/was taken or should be taken
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 0..1 integer The order of the dosage instructions
.... text SΣ 0..1 string Free text dosage instructions e.g. SIG
.... additionalInstruction Σ 0..* CodeableConcept Supplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness"
Binding: SNOMEDCTAdditionalDosageInstructions (example): A coded concept identifying additional instructions such as "take with water" or "avoid operating heavy machinery".


.... patientInstruction Σ 0..1 string Patient or consumer oriented instructions
.... timing SΣ 0..1 Timing When medication should be administered
.... asNeeded[x] Σ 0..1 Take "as needed" (for x)
Binding: SNOMEDCTMedicationAsNeededReasonCodes (example): A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.

..... asNeededBoolean boolean
..... asNeededCodeableConcept CodeableConcept
.... site Σ 0..1 CodeableConcept Body site to administer to
Binding: SNOMEDCTAnatomicalStructureForAdministrationSiteCodes (example): A coded concept describing the site location the medicine enters into or onto the body.

.... route S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Medicine Route of Administration - IPS (preferred): EDQM Standards Terms

.... method Σ 0..1 CodeableConcept Technique for administering medication
Binding: SNOMEDCTAdministrationMethodCodes (example): A coded concept describing the technique by which the medicine is administered.

.... doseAndRate Σ 0..* Element Amount of medication administered
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... type Σ 0..1 CodeableConcept The kind of dose or rate specified
Binding: DoseAndRateType (example): The kind of dose or rate specified.

..... dose[x] Σ 0..1 Amount of medication per dose
...... doseRange Range
...... doseQuantity Quantity(SimpleQuantity)
..... rate[x] Σ 0..1 Amount of medication per unit of time
...... rateRatio Ratio
...... rateRange Range
...... rateQuantity Quantity(SimpleQuantity)
.... maxDosePerPeriod Σ 0..1 Ratio Upper limit on medication per unit of time
.... maxDosePerAdministration Σ 0..1 SimpleQuantity Upper limit on medication per administration
.... maxDosePerLifetime Σ 0..1 SimpleQuantity Upper limit on medication per lifetime of the patient

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSetURI
MedicationStatement.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
MedicationStatement.statusrequiredMedication Status Codes
http://hl7.org/fhir/ValueSet/medication-statement-status|4.0.1
from the FHIR Standard
MedicationStatement.statusReasonexampleSNOMEDCTDrugTherapyStatusCodes
http://hl7.org/fhir/ValueSet/reason-medication-status-codes
from the FHIR Standard
MedicationStatement.categorypreferredMedication usage category codes
http://hl7.org/fhir/ValueSet/medication-statement-category
from the FHIR Standard
MedicationStatement.medication[x]exampleMedicationCodesUvIps
http://hl7.org/fhir/uv/ips/ValueSet/medication-example-uv-ips
MedicationStatement.medication[x]:medicationCodeableConceptextensibleValueSet-VN_Core_Medication_Code
http://fhir.ehealth.gov.vn/core/ValueSet/vn-medication-code
from this IG
MedicationStatement.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
MedicationStatement.reasonCodeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
MedicationStatement.dosage.additionalInstructionexampleSNOMEDCTAdditionalDosageInstructions
http://hl7.org/fhir/ValueSet/additional-instruction-codes
from the FHIR Standard
MedicationStatement.dosage.asNeeded[x]exampleSNOMEDCTMedicationAsNeededReasonCodes
http://hl7.org/fhir/ValueSet/medication-as-needed-reason
from the FHIR Standard
MedicationStatement.dosage.siteexampleSNOMEDCTAnatomicalStructureForAdministrationSiteCodes
http://hl7.org/fhir/ValueSet/approach-site-codes
from the FHIR Standard
MedicationStatement.dosage.routepreferredRouteOfAdminUvIps
http://hl7.org/fhir/uv/ips/ValueSet/medicine-route-of-administration
MedicationStatement.dosage.methodexampleSNOMEDCTAdministrationMethodCodes
http://hl7.org/fhir/ValueSet/administration-method-codes
from the FHIR Standard
MedicationStatement.dosage.doseAndRate.typeexampleDoseAndRateType
http://hl7.org/fhir/ValueSet/dose-rate-type
from the FHIR Standard

Constraints

Constraints

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