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: Tổng phân tích nước tiểu (10 thông số)

Bản thô xml | Tải xuống

    <Observation xmlns="http://hl7.org/fhir">
      <id value="ExampleObservationLabUrinalysis"/>
      <meta>
        <profile
                 value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab"/>
      </meta>
      <language value="vi"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Observation ExampleObservationLabUrinalysis</b></p><a name="ExampleObservationLabUrinalysis"> </a><a name="hcExampleObservationLabUrinalysis"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-vn-core-observation-lab.html">Xét nghiệm VN Core — VN Core Observation Laboratory Profile</a></p></div><p><b>status</b>: Final</p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span></p><p><b>code</b>: <span title="Codes:{http://loinc.org 24356-8}">Tổng phân tích nước tiểu (10 thông số)</span></p><p><b>subject</b>: <a href="Patient-ExamplePatientNguyenVanAn.html">Nguyễn Văn An</a></p><p><b>encounter</b>: <a href="Encounter-ExampleEncounterOutpatient.html">Encounter: extension = Khám chữa bệnh ban đầu; status = finished; class = ambulatory (ActCode#AMB); period = 2026-03-19 08:30:00+0700 --&gt; 2026-03-19 11:00:00+0700; reasonCode = </a></p><p><b>effective</b>: 2026-04-20 09:00:00+0700</p><p><b>performer</b>: <a href="Practitioner-ExamplePractitionerBSCKII.html">BS CKII Nguyễn Thị Lan</a></p><p><b>interpretation</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation N}">Normal</span></p><p><b>note</b>: </p><blockquote><div><p>Tổng phân tích nước tiểu 10 thông số — tất cả trong giới hạn bình thường. Không có protein niệu, glucose niệu. Bạch cầu niệu 1–2/HPF — không gợi ý nhiễm trùng đường tiết niệu.</p>
    </div></blockquote><p><b>specimen</b>: <a href="Specimen-ExampleSpecimenUrineMidstream.html">Mẫu nước tiểu giữa dòng</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://loinc.org 2756-5}">pH nước tiểu</span></p><p><b>value</b>: 6 [pH]<span style="background: LightGoldenRodYellow"> (Details: UCUM  code[pH] = '[pH]')</span></p><h3>ReferenceRanges</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td>5 [pH]<span style="background: LightGoldenRodYellow"> (Details: UCUM  code[pH] = '[pH]')</span></td><td>8 [pH]<span style="background: LightGoldenRodYellow"> (Details: UCUM  code[pH] = '[pH]')</span></td><td>5.0 – 8.0</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://loinc.org 2965-2}">Tỷ trọng nước tiểu</span></p><p><b>value</b>: 1.020</p><h3>ReferenceRanges</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Text</b></td></tr><tr><td style="display: none">*</td><td>1.005 – 1.030</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://loinc.org 2888-6}">Protein niệu</span></p><p><b>value</b>: Âm tính (negative)</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://loinc.org 2349-9}">Glucose niệu</span></p><p><b>value</b>: Âm tính (negative)</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{http://loinc.org 5821-4}">Bạch cầu niệu (WBC/HPF)</span></p><p><b>value</b>: 1 – 2 / HPF (bình thường)</p></blockquote></div>
      </text>
      <status value="final"/>
      <category>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="24356-8"/>
          <display value="Urinalysis complete panel - Urine"/>
        </coding>
        <text value="Tổng phân tích nước tiểu (10 thông số)"/>
      </code>
      <subject>🔗
        <reference value="Patient/ExamplePatientNguyenVanAn"/>
        <display value="Nguyễn Văn An"/>
      </subject>
      <encounter>🔗
        <reference value="Encounter/ExampleEncounterOutpatient"/>
      </encounter>
      <effectiveDateTime value="2026-04-20T09:00:00+07:00"/>
      <performer>🔗
        <reference value="Practitioner/ExamplePractitionerBSCKII"/>
        <display value="BS CKII Nguyễn Thị Lan"/>
      </performer>
      <interpretation>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="N"/>
          <display value="Normal"/>
        </coding>
      </interpretation>
      <note>
        <text
              value="Tổng phân tích nước tiểu 10 thông số — tất cả trong giới hạn bình thường. Không có protein niệu, glucose niệu. Bạch cầu niệu 1–2/HPF — không gợi ý nhiễm trùng đường tiết niệu."/>
      </note>
      <specimen>🔗
        <reference value="Specimen/ExampleSpecimenUrineMidstream"/>
        <display value="Mẫu nước tiểu giữa dòng"/>
      </specimen>
      <component>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="2756-5"/>
            <display value="pH of Urine"/>
          </coding>
          <text value="pH nước tiểu"/>
        </code>
        <valueQuantity>
          <value value="6"/>
          <unit value="[pH]"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="[pH]"/>
        </valueQuantity>
        <referenceRange>
          <low>
            <value value="5"/>
            <unit value="[pH]"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="[pH]"/>
          </low>
          <high>
            <value value="8"/>
            <unit value="[pH]"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="[pH]"/>
          </high>
          <text value="5.0 – 8.0"/>
        </referenceRange>
      </component>
      <component>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="2965-2"/>
            <display value="Specific gravity of Urine"/>
          </coding>
          <text value="Tỷ trọng nước tiểu"/>
        </code>
        <valueString value="1.020"/>
        <referenceRange>
          <text value="1.005 – 1.030"/>
        </referenceRange>
      </component>
      <component>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="2888-6"/>
            <display value="Protein [Mass/volume] in Urine"/>
          </coding>
          <text value="Protein niệu"/>
        </code>
        <valueString value="Âm tính (negative)"/>
      </component>
      <component>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="2349-9"/>
            <display value="Glucose [Presence] in Urine"/>
          </coding>
          <text value="Glucose niệu"/>
        </code>
        <valueString value="Âm tính (negative)"/>
      </component>
      <component>
        <code>
          <coding>
            <system value="http://loinc.org"/>
            <code value="5821-4"/>
            <display
                     value="Leukocytes [#/area] in Urine sediment by Microscopy high power field"/>
          </coding>
          <text value="Bạch cầu niệu (WBC/HPF)"/>
        </code>
        <valueString value="1 – 2 / HPF (bình thường)"/>
      </component>
    </Observation>