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: Chẩn đoán lượt khám VN Core — VN Core Encounter Diagnosis Condition Profile

URL chính thức: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-condition-diagnosis | Phiên bản: 0.5.0 | Làm nổi bật phần thay đổi?
| Computable Name: VNCoreConditionDiagnosis
Bản quyền/Pháp lý: Căn cứ pháp lý Việt Nam: QĐ 4469/QĐ-BYT ngày 28/10/2020; QĐ 98/QĐ-BYT ngày 14/01/2022; TT 06/2026/TT-BYT (ban hành 02/04/2026, hiệu lực 01/07/2026 — future-effective); QĐ 3176/QĐ-BYT ngày 29/10/2024 (MA_BENH/MA_BENHKHAC).

Profile con của VNCoreCondition cho chẩn đoán được ghi nhận trong một lượt khám/điều trị tại Việt Nam. ICD-10 VN là coding bắt buộc theo QĐ 4469/QĐ-BYT (28/10/2020), bổ sung mã COVID-19 theo QĐ 98/QĐ-BYT (14/01/2022) và hướng dẫn mã hóa theo TT 06/2026/TT-BYT (ban hành 02/04/2026, hiệu lực 01/07/2026 — future-effective). Category được cố định là encounter-diagnosis để phù hợp ghi nhận chẩn đoán trong hồ sơ KCB và dữ liệu đầu ra theo QĐ 3176/QĐ-BYT (29/10/2024), trường MA_BENH/MA_BENHKHAC.

Usages:

- Examples for this Profile: Condition/ExampleConditionAppendicitis, Condition/ExampleConditionDiabetes, Condition/ExampleConditionMinimal, Condition/ExampleConditionMultiCKD... Show 5 more, Condition/ExampleConditionMultiDM, Condition/ExampleConditionMultiHTN, Condition/ExampleConditionPneumonia, Condition/ExampleConditionSNOMEDVN and Condition/ExampleConditionYHCTYeuThong

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
--- | --- | --- | --- | ---
Condition | C | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category | S | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
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 chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S Σ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
code | S Σ | 1..1 | code | Mã bệnh ICD-10 VN
display | S Σ | 0..1 | string | Tên chẩn đoán ICD-10 VN
coding:snomedct | S Σ | 0..1 | Coding | Mã SNOMED CT tương đương
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code | S Σ | 1..1 | code | Mã SNOMED CT
display | S Σ | 0..1 | string | Tên chẩn đoán SNOMED CT
coding:yhct | Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
code | Σ | 1..1 | code | Mã U YHCT
display | Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | S Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
onset[x] | S Σ | 0..1 |  | Thời điểm khởi phát
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
recordedDate | S Σ | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
recorder | S Σ | 0..1 | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) | Người ghi chẩn đoán
note | S | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.5.0 | This IG
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG
Condition.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | 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
--- | --- | --- | --- | ---
Condition |  | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses
category |  | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám 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/condition-category
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
code |  |  |  |
Slices for coding |  | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
code | S | 1..1 | code | Mã bệnh ICD-10 VN
display | S | 0..1 | string | Tên chẩn đoán ICD-10 VN
coding:snomedct | S | 0..1 | Coding | Mã SNOMED CT tương đương
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code | S | 1..1 | code | Mã SNOMED CT
display | S | 0..1 | string | Tên chẩn đoán SNOMED CT
coding:yhct |  | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
code |  | 1..1 | code | Mã U YHCT
display |  | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
encounter | S | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
recordedDate | S | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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 | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category | S | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
severity |  | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code | S Σ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S Σ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Mã bệnh ICD-10 VN
display | S Σ | 0..1 | string | Tên chẩn đoán ICD-10 VN
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
coding:snomedct | S Σ | 0..1 | Coding | Mã SNOMED CT tương đương
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Mã SNOMED CT
display | S Σ | 0..1 | string | Tên chẩn đoán SNOMED CT
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
coding:yhct | Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 1..1 | code | Mã U YHCT
display | Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | S Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
onset[x] | S Σ | 0..1 |  | Thời điểm khởi phát
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
abatement[x] | C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
recorder | S Σ | 0..1 | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) | Người ghi chẩn đoán
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
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
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment
type |  | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence | C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | S | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📍4.0.1 | FHIR Std.
Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.5.0 | This IG
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG
Condition.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | evidence SHALL have code or details | `code.exists() or detail.exists()`
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | 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: 6 elements(4 nested mandatory elements)
Must-Support: 8 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the values of Condition.code.coding

Dạng xem phần tử chính

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category | S | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
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 chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S Σ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
code | S Σ | 1..1 | code | Mã bệnh ICD-10 VN
display | S Σ | 0..1 | string | Tên chẩn đoán ICD-10 VN
coding:snomedct | S Σ | 0..1 | Coding | Mã SNOMED CT tương đương
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code | S Σ | 1..1 | code | Mã SNOMED CT
display | S Σ | 0..1 | string | Tên chẩn đoán SNOMED CT
coding:yhct | Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
code | Σ | 1..1 | code | Mã U YHCT
display | Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | S Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
onset[x] | S Σ | 0..1 |  | Thời điểm khởi phát
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
recordedDate | S Σ | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
recorder | S Σ | 0..1 | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) | Người ghi chẩn đoán
note | S | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.5.0 | This IG
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG
Condition.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | 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
--- | --- | --- | --- | ---
Condition |  | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses
category |  | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám 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/condition-category
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
code |  |  |  |
Slices for coding |  | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
code | S | 1..1 | code | Mã bệnh ICD-10 VN
display | S | 0..1 | string | Tên chẩn đoán ICD-10 VN
coding:snomedct | S | 0..1 | Coding | Mã SNOMED CT tương đương
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code | S | 1..1 | code | Mã SNOMED CT
display | S | 0..1 | string | Tên chẩn đoán SNOMED CT
coding:yhct |  | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
code |  | 1..1 | code | Mã U YHCT
display |  | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
encounter | S | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
recordedDate | S | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG

Dạng xem SnapshotView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | VNCoreCondition | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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 | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái lâm sàng Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | Trạng thái xác minh Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category | S | 1..1 | CodeableConcept | Phân loại chẩn đoán lượt khám Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. 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/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 1..1 | string | Representation defined by the system Fixed Value: Encounter Diagnosis
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
severity |  | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code | S Σ | 1..1 | CodeableConcept | Mã chẩn đoán (ICD-10 / SNOMED CT) Binding: Mã chẩn đoán — VN Core Condition Code ValueSet (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system
coding:icd10vn | S Σ | 1..1 | Coding | Mã ICD-10 Việt Nam Binding: ICD-10 Việt Nam — VN ICD-10 ValueSet (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/sid/icd-10
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Mã bệnh ICD-10 VN
display | S Σ | 0..1 | string | Tên chẩn đoán ICD-10 VN
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
coding:snomedct | S Σ | 0..1 | Coding | Mã SNOMED CT tương đương
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Mã SNOMED CT
display | S Σ | 0..1 | string | Tên chẩn đoán SNOMED CT
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
coding:yhct | Σ | 0..1 | Coding | Mã bệnh danh/thể lâm sàng YHCT
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-disease-cs
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 1..1 | code | Mã U YHCT
display | Σ | 0..1 | string | Tên bệnh danh/thể lâm sàng YHCT
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
bodySite | S Σ | 0..* | CodeableConcept | Vị trí giải phẫu Binding: Vị trí giải phẫu — VN Core Body Site ValueSet (preferred)
subject | S Σ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Bệnh nhân
encounter | S Σ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan
onset[x] | S Σ | 0..1 |  | Thời điểm khởi phát
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
abatement[x] | C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 1..1 | dateTime | Ngày ghi nhận chẩn đoán
recorder | S Σ | 0..1 | Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile) | Người ghi chẩn đoán
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
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
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment
type |  | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence | C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | S | 0..* | Annotation | Ghi chú lâm sàng về chẩn đoán
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📍4.0.1 | FHIR Std.
Condition.code | Base | extensible | Mã chẩn đoán — VN Core Condition Code ValueSet | 📦0.5.0 | This IG
Condition.code.coding:icd10vn | Base | required | ICD-10 Việt Nam — VN ICD-10 ValueSet | 📦0.5.0 | This IG
Condition.bodySite | Base | preferred | Vị trí giải phẫu — VN Core Body Site ValueSet | 📦0.5.0 | This IG
Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | evidence SHALL have code or details | `code.exists() or detail.exists()`
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | 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 | Condition | 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 | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | 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: 6 elements(4 nested mandatory elements)
Must-Support: 8 elements
Fixed: 3 elements

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the values of Condition.code.coding

Biểu diễn khác của hồ sơ: CSV, Excel, Schematron