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

## Hồ sơ tài nguyên: Báo cáo Giải phẫu bệnh VN Core — VN Core Pathology DiagnosticReport

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report-pathology | Phiên bản: 0.5.0 | Làm nổi bật phần thay đổi?
| Computable Name: VNCoreDiagnosticReportPathology
Bản quyền/Pháp lý: Bộ Y tế Việt Nam — QĐ 1227/QĐ-BYT (11/4/2025), QĐ 2427/QĐ-BYT (25/7/2025), QĐ 2493/QĐ-BYT (08/2025), TT 23/2024/TT-BYT, TT 13/2025/TT-BYT, TT 38/2024/TT-BYT, QĐ 3176/QĐ-BYT (29/10/2024), QĐ 697/QĐ-BYT (19/3/2026).

Profile DiagnosticReport giải phẫu bệnh cho Việt Nam, áp dụng cho mô bệnh học, tế bào học và báo cáo GPB liên quan mẫu bệnh phẩm. Kế thừa VNCoreDiagnosticReport và siết category theo HL7 v2-0074 PAT cùng nhóm chi phí XN vì QĐ 697/QĐ-BYT gộp GPB vào nhóm xét nghiệm. Căn cứ: QĐ 1227/QĐ-BYT (11/4/2025) — nhóm Giải phẫu bệnh 81 mã; QĐ 2427/QĐ-BYT (25/7/2025) — SNOMED CT VN Body Structure phục vụ bodySite; QĐ 2493/QĐ-BYT (08/2025) — SNOMED CT VN Morphologic Abnormality phục vụ conclusionCode với binding extensible; TT 23/2024/TT-BYT — danh mục kỹ thuật hiện hành; TT 13/2025/TT-BYT Điều 1, 3 — bệnh án điện tử, lưu trữ và xác nhận điện tử; TT 38/2024/TT-BYT — Hệ thống thông tin khám bệnh, chữa bệnh; QĐ 3176/QĐ-BYT (29/10/2024) — XML3/XML6: MA_DICH_VU, KET_QUA, MA_LOAI_DVKT; QĐ 697/QĐ-BYT (19/3/2026) — nhóm chi phí 3 Xét nghiệm.

Usages:

- Examples for this Profile: DiagnosticReport/ExampleDiagnosticReportPathology

You can also check for usages in the FHIR IG Statistics

### Các dạng xem hình thức của nội dung hồ sơ

Mô tả profile, differential, snapshot và các biểu diễn liên quan.

- Bảng phần tử chính
- Bảng Differential
- Bảng Snapshot
- Thống kê/Tham chiếu
- Tất cả

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Trạng thái báo cáo Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | S Σ | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH) Slice: Unordered, Open by pattern:$this Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible)
category:diagnosticService | S Σ | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:vnCostCategory | S Σ | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Mã xét nghiệm/CĐHA (LOINC hoặc mã CLS VN per QĐ 1227) Binding: Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
effective[x] | S Σ | 0..1 |  | Thời điểm thực hiện
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | Ngày phát hành kết quả
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
result | S | 0..* | Reference(Observation) | Kết quả chi tiết (Observation)
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm | S | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:diagnosticService | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:vnCostCategory | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.code | Base | extensible | Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet | 📦0.5.0 | This IG
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If 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-4 | error | DiagnosticReport | If 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-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
category |  | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH)
Slices for category |  |  |  | Content/Rules for all slices
category:diagnosticService | S | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Required Pattern: At least the following
coding |  | 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/v2-0074
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
category:vnCostCategory | S | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
imagingStudy |  | 0..0 |  | Reference to full details of imaging associated with the diagnostic report
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm |  | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định cận lâm sàng gốc
status | ?!S Σ | 1..1 | code | Trạng thái báo cáo Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | S Σ | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH) Slice: Unordered, Open by pattern:$this Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible)
category:diagnosticService | S Σ | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:vnCostCategory | S Σ | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Mã xét nghiệm/CĐHA (LOINC hoặc mã CLS VN per QĐ 1227) Binding: Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
effective[x] | S Σ | 0..1 |  | Thời điểm thực hiện
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | Ngày phát hành kết quả
performer | Σ | 0..* | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện / phê duyệt kết quả
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
result | S | 0..* | Reference(Observation) | Kết quả chi tiết (Observation)
media | Σ | 0..* | BackboneElement | Key images associated with this report
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
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm | S | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:diagnosticService | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:vnCostCategory | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.code | Base | extensible | Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet | 📦0.5.0 | This IG
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If 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-4 | error | DiagnosticReport | If 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-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Summary

Mandatory: 3 elements
Must-Support: 5 elements
Prohibited: 1 element

Dạng xem phần tử chính

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Trạng thái báo cáo Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | S Σ | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH) Slice: Unordered, Open by pattern:$this Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible)
category:diagnosticService | S Σ | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:vnCostCategory | S Σ | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Mã xét nghiệm/CĐHA (LOINC hoặc mã CLS VN per QĐ 1227) Binding: Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
effective[x] | S Σ | 0..1 |  | Thời điểm thực hiện
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | Ngày phát hành kết quả
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
result | S | 0..* | Reference(Observation) | Kết quả chi tiết (Observation)
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm | S | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:diagnosticService | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:vnCostCategory | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.code | Base | extensible | Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet | 📦0.5.0 | This IG
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If 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-4 | error | DiagnosticReport | If 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-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Dạng xem Differential

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
category |  | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH)
Slices for category |  |  |  | Content/Rules for all slices
category:diagnosticService | S | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Required Pattern: At least the following
coding |  | 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/v2-0074
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
category:vnCostCategory | S | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
imagingStudy |  | 0..0 |  | Reference to full details of imaging associated with the diagnostic report
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm |  | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

Dạng xem SnapshotView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | VNCoreDiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định cận lâm sàng gốc
status | ?!S Σ | 1..1 | code | Trạng thái báo cáo Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
Slices for category | S Σ | 2..* | CodeableConcept | Nhóm CLS: xét nghiệm (LAB), hình ảnh (RAD), chức năng (OTH) Slice: Unordered, Open by pattern:$this Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible)
category:diagnosticService | S Σ | 1..1 | CodeableConcept | HL7 v2-0074 PAT — giải phẫu bệnh Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PAT
display |  | 1..1 | string | Representation defined by the system Fixed Value: Pathology (gross & histopath, not surgical)
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:vnCostCategory | S Σ | 1..1 | CodeableConcept | QĐ 697/QĐ-BYT nhóm chi phí 3 — xét nghiệm, bao gồm GPB Binding: Loại dịch vụ y tế — VN Service Request Category ValueSet (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 3
display |  | 1..1 | string | Representation defined by the system Fixed Value: Xét nghiệm
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Mã xét nghiệm/CĐHA (LOINC hoặc mã CLS VN per QĐ 1227) Binding: Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
effective[x] | S Σ | 0..1 |  | Thời điểm thực hiện
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | Ngày phát hành kết quả
performer | Σ | 0..* | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) | Người thực hiện / phê duyệt kết quả
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen | S | 1..* | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu mô/tế bào bắt buộc cho báo cáo giải phẫu bệnh
result | S | 0..* | Reference(Observation) | Kết quả chi tiết (Observation)
media | Σ | 0..* | BackboneElement | Key images associated with this report
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
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion | S | 0..1 | string | Kết luận giải phẫu bệnh
conclusionCode | S | 0..* | CodeableConcept | Mã bất thường hình thái SNOMED CT VN Binding: Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet (extensible)
presentedForm | S | 0..* | Attachment | Phiếu trả kết quả giải phẫu bệnh đã phát hành
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std.
DiagnosticReport.category | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:diagnosticService | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.category:vnCostCategory | Base | extensible | Loại dịch vụ y tế — VN Service Request Category ValueSet | 📦0.5.0 | This IG
DiagnosticReport.code | Base | extensible | Chỉ số cận lâm sàng — VN Clinical Lab Indicator ValueSet | 📦0.5.0 | This IG
DiagnosticReport.conclusionCode | Base | extensible | Morphologic Abnormality SNOMED CT VN — VN Morphology ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DiagnosticReport | If 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-4 | error | DiagnosticReport | If 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-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Summary

Mandatory: 3 elements
Must-Support: 5 elements
Prohibited: 1 element

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