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: Thủ thuật/DVKT VN Core — VN Core Procedure Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-procedure | Phiên bản: 0.5.0 | Làm nổi bật phần thay đổi?
| Computable Name: VNCoreProcedure

Profile Procedure cho thủ thuật và dịch vụ kỹ thuật y tế tại Việt Nam. Hỗ trợ mã hóa bằng SNOMED CT IPS Terminology (miễn phí) và danh mục DVKT VN. Căn cứ: TT 20/2014/TT-BYT, TT 39/2018/TT-BYT (danh mục DVKT), QĐ 130/QĐ-BYT (2023), sửa đổi bởi QĐ 3176/QĐ-BYT (2024) — trường MA_DVKT/MA_PTTT trong chuẩn dữ liệu BHXH, QĐ 387/QĐ-BYT (05/02/2026) — ICD-9-CM mới nhất, QĐ 4466/QĐ-BYT (2020) — ánh xạ DVKT ↔ ICD-9-CM.

Usages:

- Refer to this Profile: Bệnh án điện tử VN Core — VN Core Composition Profile
- Examples for this Profile: Procedure/ExampleProcedureAppendectomy, Procedure/ExampleProcedureIVCFilterRemoval, Procedure/ExampleProcedureMinimal, Procedure/ExampleProcedurePCIStentPlacement and Procedure/ExampleProcedureYHCTAcupuncture
- CapabilityStatements using this Profile: VN Core EMR Server CapabilityStatement and VN Core Server CapabilityStatement

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
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Trạng thái thủ thuật Binding: EventStatus (required): A code specifying the state of the procedure.
code | S Σ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code 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
performed[x] | S Σ | 0..1 |  | Thời điểm thực hiện
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
performer | Σ | 0..* | BackboneElement | The people who performed the procedure
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
actor | S Σ | 1..1 | 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
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome | Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
complication |  | 0..* | CodeableConcept | Biến chứng Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
note |  | 0..* | Annotation | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
action | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | 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
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
status | S | 1..1 | code | Trạng thái thủ thuật
code | S | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
subject | S | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter |  | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
performed[x] | S | 0..1 | dateTime, Period, string, Age, Range | Thời điểm thực hiện
performer |  |  |  |
actor | S | 1..1 | 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
bodySite | S | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome |  | 0..1 | CodeableConcept | Kết quả thủ thuật
complication |  | 0..* | CodeableConcept | Biến chứng
note |  | 0..* | Annotation | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
action | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | 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 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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 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 | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event
status | ?!S Σ | 1..1 | code | Trạng thái thủ thuật 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 | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | S Σ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code 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
performed[x] | S Σ | 0..1 |  | Thời điểm thực hiện
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | 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 | S Σ | 1..1 | 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
onBehalfOf |  | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for
location | Σ | 0..1 | Reference(Location) | 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 Σ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome | Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report |  | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure
complication |  | 0..* | CodeableConcept | Biến chứng 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 | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
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 | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
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.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std.
Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.performer.​function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std.
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | 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: 1 element
Must-Support: 9 elements

Structures

This structure refers to these other structures:

- Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
- Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
- Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
- Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
- Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
- Thiết bị y tế VN Core — VN Core Device Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-device)
- Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-implantable-device)

Extensions

This structure refers to these extensions:

- http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
- http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info

Dạng xem phần tử chính

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Trạng thái thủ thuật Binding: EventStatus (required): A code specifying the state of the procedure.
code | S Σ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code 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
performed[x] | S Σ | 0..1 |  | Thời điểm thực hiện
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
performer | Σ | 0..* | BackboneElement | The people who performed the procedure
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
actor | S Σ | 1..1 | 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
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome | Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
complication |  | 0..* | CodeableConcept | Biến chứng Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
note |  | 0..* | Annotation | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
action | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | 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
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
status | S | 1..1 | code | Trạng thái thủ thuật
code | S | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet (extensible)
subject | S | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter |  | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
performed[x] | S | 0..1 | dateTime, Period, string, Age, Range | Thời điểm thực hiện
performer |  |  |  |
actor | S | 1..1 | 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
bodySite | S | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome |  | 0..1 | CodeableConcept | Kết quả thủ thuật
complication |  | 0..* | CodeableConcept | Biến chứng
note |  | 0..* | Annotation | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
action | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.

Dạng xem SnapshotView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | 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 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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:orderDate |  | 0..1 | dateTime | Ngày y lệnh (NGAY_YL) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
extension:insuranceCostInfo |  | 0..1 | (Complex) | Thông tin BHYT: phạm vi, tỷ lệ TT, mức hưởng URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 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 | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event
status | ?!S Σ | 1..1 | code | Trạng thái thủ thuật 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 | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | S Σ | 1..1 | CodeableConcept | Mã thủ thuật/DVKT Binding: Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code 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
performed[x] | S Σ | 0..1 |  | Thời điểm thực hiện
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | 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 | S Σ | 1..1 | 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
onBehalfOf |  | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for
location | Σ | 0..1 | Reference(Location) | 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 Σ | 0..* | CodeableConcept | Vị trí giải phẫu / Huyệt châm cứu (YHCT) Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
outcome | Σ | 0..1 | CodeableConcept | Kết quả thủ thuật Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report |  | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure
complication |  | 0..* | CodeableConcept | Biến chứng 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 | Ghi chú bổ sung
focalDevice | S | 0..* | BackboneElement | Thiết bị là trọng tâm của thủ thuật
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 | S | 0..1 | CodeableConcept | Hành động trên thiết bị (implanted | explanted | manipulated) Binding: ProcedureDeviceActionCodes (preferred)
manipulated | S | 1..1 | Reference(Thiết bị y tế VN Core — VN Core Device Profile | Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile) | Thiết bị được đặt/tháo/thay/điều chỉnh
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.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std.
Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.code | Base | extensible | Mã thủ thuật/dịch vụ kỹ thuật — VN Core Procedure Code ValueSet | 📦0.5.0 | This IG
Procedure.performer.​function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std.
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📦4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | 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 | Procedure | 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 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | 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: 1 element
Must-Support: 9 elements

Structures

This structure refers to these other structures:

- Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
- Lượt khám/nhập viện VN Core — VN Core Encounter Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter)
- Nhân viên y tế VN Core — VN Core Practitioner Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner)
- Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role)
- Cơ sở y tế VN Core — VN Core Organization Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-organization)
- Thiết bị y tế VN Core — VN Core Device Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-device)
- Thiết bị cấy ghép VN Core — VN Core Implantable Device Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-implantable-device)

Extensions

This structure refers to these extensions:

- http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-order-date
- http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-insurance-cost-info

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