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 — Bệnh án ngoại trú (tăng huyết áp)

Bản thô xml | Tải xuống

    <Composition xmlns="http://hl7.org/fhir">
      <id value="ExampleCompositionEMR"/>
      <meta>
        <profile
                 value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition"/>
      </meta>
      <language value="vi"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Composition ExampleCompositionEMR</b></p><a name="ExampleCompositionEMR"> </a><a name="hcExampleCompositionEMR"> </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-composition.html">Bệnh án điện tử VN Core — VN Core Composition Profile</a></p></div><p><b>identifier</b>: <a href="NamingSystem-vn-document-number-ns.html" title="Namespace khuyến nghị cho mã tài liệu lâm sàng nội bộ do cơ sở y tế phát sinh, dùng cho Composition.identifier và DocumentReference.identifier khi chưa có NamingSystem riêng của từng cơ sở.">VNDocumentNumber</a>/BA-2026-00451</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 34108-1}">Outpatient Note</span></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>date</b>: 2026-03-22 09:30:00+0700</p><p><b>author</b>: <a href="Practitioner-ExamplePractitionerBSCKII.html">Practitioner Nguyễn Thị Lan</a></p><p><b>title</b>: Bệnh án ngoại trú</p><p><b>confidentiality</b>: restricted</p><p><b>custodian</b>: <a href="Organization-ExampleOrganizationChoRay.html">Organization Bệnh viện Chợ Rẫy</a></p></div>
      </text>
      <identifier>
        <system value="http://fhir.hl7.org.vn/core/sid/document-number"/>
        <value value="BA-2026-00451"/>
      </identifier>
      <status value="final"/>
      <type>
        <coding>
          <system value="http://loinc.org"/>
          <code value="34108-1"/>
          <display value="Outpatient Note"/>
        </coding>
      </type>
      <subject>🔗
        <reference value="Patient/ExamplePatientNguyenVanAn"/>
      </subject>
      <encounter>🔗
        <reference value="Encounter/ExampleEncounterOutpatient"/>
      </encounter>
      <date value="2026-03-22T09:30:00+07:00"/>
      <author>🔗
        <reference value="Practitioner/ExamplePractitionerBSCKII"/>
      </author>
      <title value="Bệnh án ngoại trú"/>
      <confidentiality value="R"/>
      <custodian>🔗
        <reference value="Organization/ExampleOrganizationChoRay"/>
      </custodian>
      <section>
        <title value="Lý do đến khám"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10154-3"/>
            <display value="Chief complaint Narrative - Reported"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Đau đầu, chóng mặt kéo dài 2 tuần. Tiền sử tăng huyết áp chưa điều trị.</div>
        </text>
      </section>
      <section>
        <title value="Chẩn đoán"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="29548-5"/>
            <display value="Diagnosis Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Tăng huyết áp nguyên phát, độ II (I10 — ICD-10 VN per QĐ 4469/QĐ-BYT).</div>
        </text>
      </section>
      <section>
        <title value="Thuốc điều trị"/>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="10160-0"/>
            <display value="History of Medication use Narrative"/>
          </coding>
        </code>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">Amlodipine 5mg x 1 viên/ngày, uống sáng. Tái khám sau 2 tuần.</div>
        </text>
      </section>
    </Composition>