HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.5.0 - Draft for Community Review

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Local Development build (v0.5.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## : Ví dụ: Báo cáo xét nghiệm sinh hóa

Bản thô xml | Tải xuống

    <DiagnosticReport xmlns="http://hl7.org/fhir">
      <id value="ExampleDiagnosticReportLab"/>
      <meta>
        <profile
                 value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report-lab"/>
      </meta>
      <language value="vi"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: DiagnosticReport ExampleDiagnosticReportLab</b></p><a name="ExampleDiagnosticReportLab"> </a><a name="hcExampleDiagnosticReportLab"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-diagnostic-report-lab.html">Báo cáo Xét nghiệm VN Core — VN Core Lab DiagnosticReport</a></p></div><h2><span title="Codes:{http://loinc.org 24323-8}">Xét nghiệm sinh hóa máu</span> (<span title="Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 LAB}">Laboratory</span>, <span title="Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs 3}">Xét nghiệm</span>) </h2><table class="grid"><tr><td>Subject</td><td>Nguyễn Văn An Male, DoB: 1985-03-15 ( Căn cước công dân: VNCCCD#001085012345)</td></tr><tr><td>When For</td><td>2026-03-17 08:30:00+0700</td></tr><tr><td>Reported</td><td>2026-03-17 14:00:00+0700</td></tr><tr><td>Performer</td><td> <a href="Organization-ExampleOrganizationChoRay.html">Khoa Xét nghiệm — BV Chợ Rẫy</a></td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Reference Range</b></td><td><b>Flags</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-ExampleObservationLabGlucose.html"><span title="Codes:{http://loinc.org 14771-0}">Glucose máu lúc đói</span></a></td><td>6.8 mmol/L<span style="background: LightGoldenRodYellow"> (Details: UCUM  codemmol/L = 'mmol/L')</span></td><td>3.9 - 6.1 mmol/L</td><td>Final, <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}">High</span></td><td>2026-03-19 09:20:00+0700</td></tr></table><p>Glucose tăng nhẹ (6.8 mmol/L, ref: 3.9–6.1). Cần theo dõi HbA1c. Creatinine trong giới hạn bình thường.</p><p><b>Coded Conclusions:</b></p><ul><li><span title="Codes:{http://hl7.org/fhir/sid/icd-10 R73.0}">Tăng glucose máu</span></li></ul></div>
      </text>
      <basedOn>🔗
        <reference value="ServiceRequest/ExampleServiceRequestLabGlucose"/>
        <display value="Yêu cầu xét nghiệm đường huyết lúc đói"/>
      </basedOn>
      <status value="final"/>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
          <code value="LAB"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <category>
        <coding>
          <system
                  value="http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs"/>
          <code value="3"/>
          <display value="Xét nghiệm"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="24323-8"/>
          <display value="Comprehensive metabolic 2000 panel - Serum or Plasma"/>
        </coding>
        <text value="Xét nghiệm sinh hóa máu"/>
      </code>
      <subject>🔗
        <reference value="Patient/ExamplePatientNguyenVanAn"/>
        <display value="Nguyễn Văn An"/>
      </subject>
      <encounter>🔗
        <reference value="Encounter/ExampleEncounterOutpatient"/>
      </encounter>
      <effectiveDateTime value="2026-03-17T08:30:00+07:00"/>
      <issued value="2026-03-17T14:00:00+07:00"/>
      <performer>🔗
        <reference value="Organization/ExampleOrganizationChoRay"/>
        <display value="Khoa Xét nghiệm — BV Chợ Rẫy"/>
      </performer>
      <specimen>🔗
        <reference value="Specimen/ExampleSpecimenSerumChemistry"/>
        <display value="Mẫu huyết thanh xét nghiệm sinh hóa"/>
      </specimen>
      <result>🔗
        <reference value="Observation/ExampleObservationLabGlucose"/>
        <display value="Glucose máu: 7.2 mmol/L"/>
      </result>
      <conclusion
                  value="Glucose tăng nhẹ (6.8 mmol/L, ref: 3.9–6.1). Cần theo dõi HbA1c. Creatinine trong giới hạn bình thường."/>
      <conclusionCode>
        <coding>
          <system value="http://hl7.org/fhir/sid/icd-10"/>
          <code value="R73.0"/>
          <display value="Abnormal glucose tolerance test"/>
        </coding>
        <text value="Tăng glucose máu"/>
      </conclusionCode>
    </DiagnosticReport>