Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Local Development build (v0.6.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Ví dụ: Sổ Sức khỏe điện tử (Patient Summary) — Nguyễn Văn An

Bản thô xml | Tải xuống

<Composition xmlns="http://hl7.org/fhir">
  <id value="ExampleCompositionHealthRecordSummary"/>
  <meta>
    <profile
             value="http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition-health-record-summary"/>
  </meta>
  <language value="vi"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><h1>Sổ Sức khỏe điện tử — Nguyễn Văn An</h1><p>Tóm tắt: Tăng huyết áp, Đái tháo đường type 2. Dị ứng Penicillin. Đang điều trị Amlodipine. Phân loại sức khỏe gần nhất: Loại II.</p></div>
  </text>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="60591-5"/>
      <display value="Patient summary Document"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/ExamplePatientNguyenVanAn"/>
  </subject>
  <date value="2026-06-02T08:00:00+07:00"/>
  <author>🔗 
    <reference value="Organization/ExampleOrganizationHealthCheckupFacility"/>
  </author>
  <title value="Sổ Sức khỏe điện tử"/>
  <attester>
    <mode value="legal"/>
    <party>🔗 
      <reference
                 value="Organization/ExampleOrganizationHealthCheckupFacility"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/ExampleOrganizationHealthCheckupFacility"/>
  </custodian>
  <section>
    <title value="Tiền sử dị ứng"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies and adverse reactions Document"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="AllergyIntolerance/ExampleAllergyPenicillin"/>
    </entry>
  </section>
  <section>
    <title value="Tiền sử bệnh tật"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11450-4"/>
        <display value="Problem list - Reported"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Condition/ExampleConditionProblemHypertension"/>
    </entry>
    <entry>🔗 
      <reference value="Condition/ExampleConditionDiabetes"/>
    </entry>
  </section>
  <section>
    <title value="Thuốc điều trị"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="History of Medication use Narrative"/>
      </coding>
    </code>
    <entry>🔗 
      <reference
                 value="MedicationRequest/ExampleMedicationRequestHypertension"/>
    </entry>
  </section>
  <section>
    <title value="Tiền sử tiêm chủng"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11369-6"/>
        <display value="History of Immunization note"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Immunization/ExampleImmunizationTCMR"/>
    </entry>
  </section>
  <section>
    <title value="Kết quả xét nghiệm"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="30954-2"/>
        <display value="Relevant diagnostic tests/laboratory data note"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ExampleObservationLabGlucose"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/ExampleObservationLabHbA1c"/>
    </entry>
  </section>
  <section>
    <title value="Phẫu thuật, thủ thuật"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47519-4"/>
        <display value="History of Procedures Document"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Procedure/ExampleProcedureAppendectomy"/>
    </entry>
  </section>
  <section>
    <title value="Chỉ số theo dõi chính"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital signs note"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/ExampleObservationVitalBP"/>
    </entry>
    <entry>🔗 
      <reference value="Observation/ExampleObservationVitalBMI"/>
    </entry>
  </section>
  <section>
    <title value="Khám sức khỏe định kỳ"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="34117-2"/>
        <display value="History and physical note"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Khám sức khỏe định kỳ gần nhất: phân loại sức khỏe Loại I (Rất khoẻ). Hồ sơ Khám sức khỏe đầy đủ được lưu dưới dạng tài liệu KSK riêng (VNCoreCompositionHealthCheckup).</div>
    </text>
  </section>
</Composition>