Visit the FHIR website
Search FHIR Cục Công nghệ thông tin - Bộ Y tế

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: VNCoreObservationReviewOfSystems

Thông tin toàn trạng người bệnh

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-observation-reviewofsystems

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 Observation

Summary

Mandatory: 5 elements
Must-Support: 7 elements
Fixed: 3 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.category

Profile này được dựa trên Resource Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* Observation Measurements and simple assertions
... identifier S 0..* Identifier Business Identifier for observation
... status S 1..1 code registered | preliminary | final | amended +
Fixed Value: final
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:sliceCategory 1..1 CodeableConcept Classification of type of observation
Fixed Value: As shown
..... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 1..1 string Representation defined by the system
Fixed Value: Physical Exam
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... display 1..1 string Representation defined by the system
Fixed Value: Review of systems Narrative - Reported
... subject 1..1 Reference(Patient Profile - VN Core R4 | Patient | Group | Device | Location) Who and/or what the observation is about
... encounter 1..1 Reference(Encounter Profile - VN Core R4 | Encounter) Healthcare event during which this observation is made
... effective[x] S 0..1 dateTime, Period, Timing, instant Clinically relevant time/time-period for observation
... issued S 0..1 instant Date/Time this version was made available
... performer S 0..* Reference(Practitioner Profile - VN Core R4) Who is responsible for the observation
... value[x] S 1..1 string Actual result
... interpretation 0..0
... bodySite S 0..1 CodeableConcept Observed body part
... referenceRange 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... 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 Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.


Fixed Value: final
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:sliceCategory 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Fixed Value: As shown
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..0 string Unique id for inter-element referencing
...... extension 0..0 Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..0 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 1..1 string Representation defined by the system
Fixed Value: Physical Exam
...... userSelected 0..0 boolean If this coding was chosen directly by the user
..... text 0..0 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Fixed Value: As shown
.... id 0..0 string Unique id for inter-element referencing
.... extension 0..0 Extension Additional content defined by implementations
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..0 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... display 1..1 string Representation defined by the system
Fixed Value: Review of systems Narrative - Reported
..... userSelected 0..0 boolean If this coding was chosen directly by the user
.... text 0..0 string Plain text representation of the concept
... subject Σ 1..1 Reference(Patient Profile - VN Core R4 | Patient | Group | Device | Location) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 1..1 Reference(Encounter Profile - VN Core R4 | Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner Profile - VN Core R4) Who is responsible for the observation
... value[x] SΣC 1..1 string Actual result
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... note 0..* Annotation Comments about the observation
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... 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
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Profile này được dựa trên Resource Observation

Summary

Mandatory: 5 elements
Must-Support: 7 elements
Fixed: 3 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of Observation.category

Differential View

Profile này được dựa trên Resource Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* Observation Measurements and simple assertions
... identifier S 0..* Identifier Business Identifier for observation
... status S 1..1 code registered | preliminary | final | amended +
Fixed Value: final
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by value:coding.system, value:coding.code
.... category:sliceCategory 1..1 CodeableConcept Classification of type of observation
Fixed Value: As shown
..... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 1..1 string Representation defined by the system
Fixed Value: Physical Exam
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... display 1..1 string Representation defined by the system
Fixed Value: Review of systems Narrative - Reported
... subject 1..1 Reference(Patient Profile - VN Core R4 | Patient | Group | Device | Location) Who and/or what the observation is about
... encounter 1..1 Reference(Encounter Profile - VN Core R4 | Encounter) Healthcare event during which this observation is made
... effective[x] S 0..1 dateTime, Period, Timing, instant Clinically relevant time/time-period for observation
... issued S 0..1 instant Date/Time this version was made available
... performer S 0..* Reference(Practitioner Profile - VN Core R4) Who is responsible for the observation
... value[x] S 1..1 string Actual result
... interpretation 0..0
... bodySite S 0..1 CodeableConcept Observed body part
... referenceRange 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... 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 Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code registered | preliminary | final | amended +
Binding: ObservationStatus (required): Codes providing the status of an observation.


Fixed Value: final
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Unordered, Open by value:coding.system, value:coding.code
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:sliceCategory 1..1 CodeableConcept Classification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.



Fixed Value: As shown
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..0 string Unique id for inter-element referencing
...... extension 0..0 Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version 0..0 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: exam
...... display 1..1 string Representation defined by the system
Fixed Value: Physical Exam
...... userSelected 0..0 boolean If this coding was chosen directly by the user
..... text 0..0 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept Type of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Fixed Value: As shown
.... id 0..0 string Unique id for inter-element referencing
.... extension 0..0 Extension Additional content defined by implementations
.... coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..0 string Unique id for inter-element referencing
..... extension 0..0 Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..0 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
..... display 1..1 string Representation defined by the system
Fixed Value: Review of systems Narrative - Reported
..... userSelected 0..0 boolean If this coding was chosen directly by the user
.... text 0..0 string Plain text representation of the concept
... subject Σ 1..1 Reference(Patient Profile - VN Core R4 | Patient | Group | Device | Location) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... encounter Σ 1..1 Reference(Encounter Profile - VN Core R4 | Encounter) Healthcare event during which this observation is made
... effective[x] SΣ 0..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
.... effectiveInstant instant
... issued SΣ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner Profile - VN Core R4) Who is responsible for the observation
... value[x] SΣC 1..1 string Actual result
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... note 0..* Annotation Comments about the observation
... bodySite S 0..1 CodeableConcept Observed body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept How it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Specimen used for this observation
... device 0..1 Reference(Device | DeviceMetric) (Measurement) Device
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... component Σ 0..* BackboneElement Component results
.... 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
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / CodeURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:sliceCategorypreferredFixed Value: exam("Physical Exam")
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.codeexampleFixed Value: LOINC Code 10187-3("Review of systems Narrative - Reported")
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Constraints

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorObservationIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorObservationIf 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-4errorObservationIf 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-5errorObservationIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceObservationA 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()
obs-6errorObservationdataAbsentReason SHALL only be present if Observation.value[x] is not present
: dataAbsentReason.empty() or value.empty()
obs-7errorObservationIf Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
: value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()