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: ALT (SGPT) — Chức năng gan bình thường

Bản thô xml | Tải xuống

    <Observation xmlns="http://hl7.org/fhir">
      <id value="ExampleObservationLabALT"/>
      <meta>
        <profile
                 value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-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: Observation ExampleObservationLabALT</b></p><a name="ExampleObservationLabALT"> </a><a name="hcExampleObservationLabALT"> </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-observation-lab.html">Xét nghiệm VN Core — VN Core Observation Laboratory Profile</a></p></div><p><b>status</b>: Final</p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span></p><p><b>code</b>: <span title="Codes:{http://loinc.org 1742-6}">ALT (SGPT) — chức năng gan</span></p><p><b>subject</b>: <a href="Patient-ExamplePatientNguyenVanAn.html">Nguyễn Văn An</a></p><p><b>encounter</b>: <a href="Encounter-ExampleEncounterOutpatient.html">Encounter: extension = Khám chữa bệnh ban đầu; status = finished; class = ambulatory (ActCode#AMB); period = 2026-03-19 08:30:00+0700 --&gt; 2026-03-19 11:00:00+0700; reasonCode = </a></p><p><b>effective</b>: 2026-04-20 08:30:00+0700</p><p><b>performer</b>: <a href="Practitioner-ExamplePractitionerBSCKII.html">BS CKII Nguyễn Thị Lan</a></p><p><b>value</b>: 28 U/L<span style="background: LightGoldenRodYellow"> (Details: UCUM  codeU/L = 'U/L')</span></p><p><b>interpretation</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}">Normal</span></p><p><b>note</b>: </p><blockquote><div><p>ALT 28 U/L — trong giới hạn bình thường. Chức năng gan bình thường. Phù hợp để tiếp tục phác đồ thuốc hiện tại. Nếu chỉ định thêm statin (phòng ngừa tim mạch), theo dõi lại ALT sau 4–8 tuần.</p>
    </div></blockquote><h3>ReferenceRanges</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td>7 U/L<span style="background: LightGoldenRodYellow"> (Details: UCUM  codeU/L = 'U/L')</span></td><td>56 U/L<span style="background: LightGoldenRodYellow"> (Details: UCUM  codeU/L = 'U/L')</span></td><td>7 – 56 U/L</td></tr></table></div>
      </text>
      <status value="final"/>
      <category>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="1742-6"/>
          <display
                   value="Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma"/>
        </coding>
        <text value="ALT (SGPT) — chức năng gan"/>
      </code>
      <subject>🔗
        <reference value="Patient/ExamplePatientNguyenVanAn"/>
        <display value="Nguyễn Văn An"/>
      </subject>
      <encounter>🔗
        <reference value="Encounter/ExampleEncounterOutpatient"/>
      </encounter>
      <effectiveDateTime value="2026-04-20T08:30:00+07:00"/>
      <performer>🔗
        <reference value="Practitioner/ExamplePractitionerBSCKII"/>
        <display value="BS CKII Nguyễn Thị Lan"/>
      </performer>
      <valueQuantity>
        <value value="28"/>
        <unit value="U/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="U/L"/>
      </valueQuantity>
      <interpretation>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="N"/>
          <display value="Normal"/>
        </coding>
      </interpretation>
      <note>
        <text
              value="ALT 28 U/L — trong giới hạn bình thường. Chức năng gan bình thường. Phù hợp để tiếp tục phác đồ thuốc hiện tại. Nếu chỉ định thêm statin (phòng ngừa tim mạch), theo dõi lại ALT sau 4–8 tuần."/>
      </note>
      <referenceRange>
        <low>
          <value value="7"/>
          <unit value="U/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="U/L"/>
        </low>
        <high>
          <value value="56"/>
          <unit value="U/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="U/L"/>
        </high>
        <text value="7 – 56 U/L"/>
      </referenceRange>
    </Observation>