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: Xét nghiệm VN Core — VN Core Observation Laboratory Profile

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

Profile Observation cho kết quả xét nghiệm lâm sàng tại Việt Nam. Sử dụng LOINC làm mã xét nghiệm (66.077 mã unique, bản dịch tiếng Việt do BYT phát hành). BYT đã ban hành bộ mã CLS quốc gia ánh xạ sang LOINC (QĐ 1227/QĐ-BYT 11/04/2025). Căn cứ: QĐ 1227/QĐ-BYT (2025), TT 13/2025/TT-BYT, QĐ 130/QĐ-BYT sửa đổi bởi QĐ 3176/QĐ-BYT (2024).

Usages:

- Refer to this Profile: Bệnh án điện tử VN Core — VN Core Composition Profile, Ghi nhận sử dụng VTYT VN Core — VN Core DeviceUseStatement Profile, Báo cáo Xét nghiệm VN Core — VN Core Lab DiagnosticReport and Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile
- Examples for this Profile: Observation/ExampleObservationLabALT, Observation/ExampleObservationLabCBC, Observation/ExampleObservationLabCreatinine, Observation/ExampleObservationLabGlucose... Show 3 more, Observation/ExampleObservationLabHbA1c, Observation/ExampleObservationLabUrinalysis and Observation/ExampleObservationSpecimenError
- 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
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
basedOn | Σ | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
status | ?!S Σ | 1..1 | code | Trạng thái (registered, preliminary, final, amended) Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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/observation-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
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 (LOINC khuyến nghị) Binding: LOINCCodes (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 | 1..1 |  | Thời điểm lấy mẫu/đo
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
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/đơn vị thực hiện xét nghiệm
value[x] | S Σ C | 0..1 |  | Kết quả xét nghiệm
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Ghi chú kết quả
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
referenceRange | C | 0..* | BackboneElement | Khoảng tham chiếu Constraints: obs-3
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:Laboratory | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | 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()`
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text | `low.exists() or high.exists() or text.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
basedOn |  | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
status | S | 1..1 | code | Trạng thái (registered, preliminary, final, amended)
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation 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/observation-category
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
code | S | 1..1 | CodeableConcept | Mã xét nghiệm (LOINC khuyến nghị) Binding: LOINCCodes (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
effective[x] | S | 1..1 | dateTime, Period, Timing, instant | Thời điểm lấy mẫu/đo
performer |  | 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/đơn vị thực hiện xét nghiệm
value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Kết quả xét nghiệm
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...)
note |  | 0..* | Annotation | Ghi chú kết quả
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
referenceRange |  | 0..* | BackboneElement | Khoảng tham chiếu
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
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 observation
basedOn | Σ | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | Trạng thái (registered, preliminary, final, amended) Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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/observation-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
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 (LOINC khuyến nghị) Binding: LOINCCodes (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
effective[x] | S Σ | 1..1 |  | Thời điểm lấy mẫu/đo
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
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/đơn vị thực hiện xét nghiệm
value[x] | S Σ C | 0..1 |  | Kết quả xét nghiệm
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Ghi chú kết quả
bodySite |  | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | C | 0..* | BackboneElement | Khoảng tham chiếu Constraints: obs-3
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
low | C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant
high | C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant
type |  | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Applicable age range, if relevant
text |  | 0..1 | string | Text based reference range in an observation
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | Σ | 0..* | BackboneElement | Component results
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
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x] | Σ | 0..1 |  | Actual component result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange |  | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:Laboratory | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.
Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.
Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std.
Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std.
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.component.​dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.component.​interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | 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()`
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text | `low.exists() or high.exists() or text.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Summary

Mandatory: 4 elements
Must-Support: 8 elements

Structures

This structure refers to these other structures:

- Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-service-request)
- 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)
- Mẫu bệnh phẩm VN Core — VN Core Specimen Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-specimen)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the values of Observation.category

Dạng xem phần tử chính

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
basedOn | Σ | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
status | ?!S Σ | 1..1 | code | Trạng thái (registered, preliminary, final, amended) Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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/observation-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
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 (LOINC khuyến nghị) Binding: LOINCCodes (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 | 1..1 |  | Thời điểm lấy mẫu/đo
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
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/đơn vị thực hiện xét nghiệm
value[x] | S Σ C | 0..1 |  | Kết quả xét nghiệm
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Ghi chú kết quả
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
referenceRange | C | 0..* | BackboneElement | Khoảng tham chiếu Constraints: obs-3
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:Laboratory | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | 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()`
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text | `low.exists() or high.exists() or text.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Dạng xem Differential

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
basedOn |  | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
status | S | 1..1 | code | Trạng thái (registered, preliminary, final, amended)
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation 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/observation-category
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
code | S | 1..1 | CodeableConcept | Mã xét nghiệm (LOINC khuyến nghị) Binding: LOINCCodes (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
effective[x] | S | 1..1 | dateTime, Period, Timing, instant | Thời điểm lấy mẫu/đo
performer |  | 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/đơn vị thực hiện xét nghiệm
value[x] | S | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Kết quả xét nghiệm
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...)
note |  | 0..* | Annotation | Ghi chú kết quả
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
referenceRange |  | 0..* | BackboneElement | Khoảng tham chiếu
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.

Dạng xem SnapshotView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
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 observation
basedOn | Σ | 0..* | Reference(Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile) | Chỉ định xét nghiệm làm căn cứ trả kết quả
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | Trạng thái (registered, preliminary, final, amended) Binding: ObservationStatus (required): Codes providing the status of an observation.
Slices for category | S | 1..* | CodeableConcept | Classification of type of observation Slice: Unordered, Open by value:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:Laboratory | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. 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/observation-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: laboratory
display |  | 1..1 | string | Representation defined by the system Fixed Value: Laboratory
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 (LOINC khuyến nghị) Binding: LOINCCodes (extensible)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
effective[x] | S Σ | 1..1 |  | Thời điểm lấy mẫu/đo
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effectiveTiming |  |  | Timing |
effectiveInstant |  |  | instant |
issued | Σ | 0..1 | instant | Date/Time this version was made available
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/đơn vị thực hiện xét nghiệm
value[x] | S Σ C | 0..1 |  | Kết quả xét nghiệm
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation | S | 0..* | CodeableConcept | Diễn giải (H, L, N, A...) Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Ghi chú kết quả
bodySite |  | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen |  | 0..1 | Reference(Mẫu bệnh phẩm VN Core — VN Core Specimen Profile) | Mẫu bệnh phẩm
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
referenceRange | C | 0..* | BackboneElement | Khoảng tham chiếu Constraints: obs-3
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
low | C | 0..1 | SimpleQuantity(4.0.1) | Low Range, if relevant
high | C | 0..1 | SimpleQuantity(4.0.1) | High Range, if relevant
type |  | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Applicable age range, if relevant
text |  | 0..1 | string | Text based reference range in an observation
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
component | Σ | 0..* | BackboneElement | Component results
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
code | Σ | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x] | Σ | 0..1 |  | Actual component result
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange |  | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:Laboratory | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | extensible | LOINC Codes | 📦4.0.1 | FHIR Std.
Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.
Observation.bodySite | Base | example | SNOMED CT Body Structures | 📍4.0.1 | FHIR Std.
Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std.
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.component.​dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.component.​interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | 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()`
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text | `low.exists() or high.exists() or text.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Summary

Mandatory: 4 elements
Must-Support: 8 elements

Structures

This structure refers to these other structures:

- Yêu cầu DVKT/Cận lâm sàng VN Core — VN Core ServiceRequest Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-service-request)
- 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)
- Mẫu bệnh phẩm VN Core — VN Core Specimen Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-specimen)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the values of Observation.category

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