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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: VNCoreProcedure

Thông tin mô tả về việc thực hiện dịch vụ kỹ thuật/phẫu thuật/thủ thuật

Đường dẫn URL chính thức của Profile này: 

http://fhir.ehealth.gov.vn/core/StructureDefinition/vn-core-procedure

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 ProcedureUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure ProcedureUvIps
... identifier S 0..* Identifier External Identifiers for this procedure
... basedOn S 0..* Reference(ServiceRequest profile - VN Core R4) A request for this procedure
... category S 0..1 CodeableConcept Classification of the procedure
... subject 1..1 Reference(Patient Profile - VN Core R4) Who the procedure was performed on
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... recorder S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who recorded the procedure
... asserter 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who asserts this procedure
... performer
.... actor 1..1 Reference(Practitioner Profile - VN Core R4) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Organization the device or practitioner was acting for
... location S 0..1 Reference(Location Profile - VN Core R4) Where the procedure happened
... bodySite 0..* CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (preferred)
... outcome S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... report S 0..* Reference(DiagnosticReport | DocumentReference | Composition | DiagnosticReport Profile - VN Core R4) Any report resulting from the procedure

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure S 0..* ProcedureUvIps An action that is being or was performed on 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 SΣ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn SΣ 0..* Reference(ServiceRequest profile - VN Core R4) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... Slices for code SΣ 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: ValueSet dành cho Mã dịch vụ kỹ thuật (preferred)
.... code:absentOrUnknownProcedure S 0..1 CodeableConceptIPS Code for absent problem or for unknown procedure
Binding: Absent or Unknown Procedures - IPS (required): A code to identify absent or unknown procedures

... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who the procedure was performed on
.... 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
... encounter SΣ 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... performed[x] SΣ 1..1 When the procedure was performed
.... performed[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... data-absent-reason S 0..1 code performed[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder SΣ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... 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 Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ 1..1 Reference(Practitioner Profile - VN Core R4) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Organization the device or practitioner was acting for
... location SΣ 0..1 Reference(Location Profile - VN Core R4) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite S 0..* CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (preferred)
... outcome S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report S 0..* Reference(DiagnosticReport | DocumentReference | Composition | DiagnosticReport Profile - VN Core R4) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... 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
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Differential View

Profile này được dựa trên Resource ProcedureUvIps

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure ProcedureUvIps
... identifier S 0..* Identifier External Identifiers for this procedure
... basedOn S 0..* Reference(ServiceRequest profile - VN Core R4) A request for this procedure
... category S 0..1 CodeableConcept Classification of the procedure
... subject 1..1 Reference(Patient Profile - VN Core R4) Who the procedure was performed on
... encounter S 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... recorder S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who recorded the procedure
... asserter 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who asserts this procedure
... performer
.... actor 1..1 Reference(Practitioner Profile - VN Core R4) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Organization the device or practitioner was acting for
... location S 0..1 Reference(Location Profile - VN Core R4) Where the procedure happened
... bodySite 0..* CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (preferred)
... outcome S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
... report S 0..* Reference(DiagnosticReport | DocumentReference | Composition | DiagnosticReport Profile - VN Core R4) Any report resulting from the procedure

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure S 0..* ProcedureUvIps An action that is being or was performed on 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 SΣ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn SΣ 0..* Reference(ServiceRequest profile - VN Core R4) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... Slices for code SΣ 1..1 CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Slice: Unordered, Open by pattern:$this
Binding: ValueSet dành cho Mã dịch vụ kỹ thuật (preferred)
.... code:absentOrUnknownProcedure S 0..1 CodeableConceptIPS Code for absent problem or for unknown procedure
Binding: Absent or Unknown Procedures - IPS (required): A code to identify absent or unknown procedures

... subject SΣ 1..1 Reference(Patient Profile - VN Core R4) Who the procedure was performed on
.... 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
... encounter SΣ 0..1 Reference(Encounter Profile - VN Core R4) Encounter created as part of
... performed[x] SΣ 1..1 When the procedure was performed
.... performed[x]All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... data-absent-reason S 0..1 code performed[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder SΣ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Practitioner Profile - VN Core R4) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... 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 Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ 1..1 Reference(Practitioner Profile - VN Core R4) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Provider Profile - VN Core R4 | HealthcareDepartment Profile - VN Core R4) Organization the device or practitioner was acting for
... location SΣ 0..1 Reference(Location Profile - VN Core R4) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite S 0..* CodeableConceptIPS, VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (preferred)
... outcome S 0..1 VNCoreCodeableConcept Concept - reference to a terminology or just text
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report S 0..* Reference(DiagnosticReport | DocumentReference | Composition | DiagnosticReport Profile - VN Core R4) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... 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
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

 

Hình thức mô tả khác: Schematron

Thông tin bổ sung

Terminology Bindings

Terminology Bindings

PathConformanceValueSetURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codepreferredValueSet-VN_Core_Procedure_Code
http://fhir.ehealth.gov.vn/core/ValueSet/vn-procedure-code
from this IG
Procedure.code:absentOrUnknownProcedurerequiredNoProceduresInfoUvIps
http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips
Procedure.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySitepreferredSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

Constraints

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