abstractbaseDefinitioncopyrightdatedescriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisherpurposestatustitletypeurlversion- Values Differ
| Left: | Nhận định lâm sàng VN Core — VN Core ClinicalImpression Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression) |
| Right: | Nhận định lâm sàng VN Core — VN Core ClinicalImpression Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression) |
| Error | StructureDefinition.version | Values for version differ: '0.8.0' vs '0.9.0' |
| Error | ClinicalImpression.subject | Type Mismatch: Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient]]) vs Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient]]) |
| Error | ClinicalImpression.encounter | Type Mismatch: Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter]]) vs Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter]]) |
| Error | ClinicalImpression.assessor | Type Mismatch: Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner], CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role]]) vs Reference([CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner], CanonicalType[http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role]]) |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/ClinicalImpression | ||
| copyright | Căn cứ pháp lý Việt Nam: TT 13/2025/TT-BYT ngày 06/06/2025. | ||
| date | 2026-06-03 | ||
| description | Profile ClinicalImpression ghi nhận **hợp lý/nhận định lâm sàng** của bác sĩ trong một lượt khám (đánh giá tổng hợp, biện luận chẩn đoán, tiên lượng). Bổ trợ cho Condition (chẩn đoán) bằng phần biện luận. Căn cứ pháp lý: - **TT 13/2025/TT-BYT** — bệnh án điện tử (nhận định/biện luận lâm sàng). / VN Core ClinicalImpression for clinical reasoning/assessment. | ||
| experimental | |||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#VN | ||
| kind | resource | ||
| name | VNCoreClinicalImpression | ||
| publisher | Omi HealthTech / VN Core FHIR Community Initiative | ||
| purpose | Lớp interoperability cho care-management (TT 13/2025/TT-BYT): ràng buộc hiện ở mức Must Support trên element nền, chưa siết invariant đặc thù VN — sẽ gia cố sau khi có bằng chứng triển khai thực địa (tránh over-constrain cản adoption). | ||
| status | draft | ||
| title | Nhận định lâm sàng VN Core — VN Core ClinicalImpression Profile | ||
| type | ClinicalImpression | ||
| url | http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression | ||
| version | 0.8.0 | 0.9.0 |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| 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 | 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 | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | Σ | 0..* | Identifier | Business identifier | Σ | 0..* | Identifier | Business identifier | |||||||||
| status | ?!SΣ | 1..1 | code | Trạng thái: in-progress, completed, entered-in-error Binding: ?? (required): The workflow state of a clinical impression. | ?!SΣ | 1..1 | code | Trạng thái: in-progress, completed, entered-in-error Binding: ?? (required): The workflow state of a clinical impression. | |||||||||
| statusReason | 0..1 | CodeableConcept | Reason for current status Binding Description: (example): Codes identifying the reason for the current state of a clinical impression. | 0..1 | CodeableConcept | Reason for current status Binding Description: (example): Codes identifying the reason for the current state of a clinical impression. | |||||||||||
| code | Σ | 0..1 | CodeableConcept | Kind of assessment performed Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | Σ | 0..1 | CodeableConcept | Kind of assessment performed Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | |||||||||
| description | Σ | 0..1 | string | Why/how the assessment was performed | Σ | 0..1 | string | Why/how the assessment was performed | |||||||||
| subject | SΣ | 1..1 | Reference(http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient) | Người bệnh được nhận định | SΣ | 1..1 | Reference(Bệnh nhân VN Core — VN Core Patient Profile) | Người bệnh được nhận định |
| ||||||||
| encounter | SΣ | 0..1 | Reference(http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-encounter) | Lượt khám liên quan | SΣ | 0..1 | Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) | Lượt khám liên quan |
| ||||||||
| effective[x] | SΣ | 0..1 | dateTime, Period | Thời điểm/khoảng nhận định | SΣ | 0..1 | dateTime, Period | Thời điểm/khoảng nhận định | |||||||||
| date | Σ | 0..1 | dateTime | When the assessment was documented | Σ | 0..1 | dateTime | When the assessment was documented | |||||||||
| assessor | SΣ | 0..1 | Reference(http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner | http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-practitioner-role) | Bác sĩ nhận định | SΣ | 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) | Bác sĩ nhận định |
| ||||||||
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||||||||
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | |||||||||
 investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | 1..1 | CodeableConcept | A name/code for the set Binding: ?? (example): A name/code for a set of investigations. | 1..1 | CodeableConcept | A name/code for the set Binding: ?? (example): A name/code for a set of investigations. | |||||||||||
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |||||||||||
| protocol | 0..* | uri | Clinical Protocol followed | 0..* | uri | Clinical Protocol followed | |||||||||||
| summary | S | 0..1 | string | Tóm tắt biện luận lâm sàng | S | 0..1 | string | Tóm tắt biện luận lâm sàng | |||||||||
| finding | S | 0..* | BackboneElement | Phát hiện/kết luận (tham chiếu Condition/Observation) | S | 0..* | BackboneElement | Phát hiện/kết luận (tham chiếu Condition/Observation) | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: ?? (example): Identification of the Condition or diagnosis. | 0..1 | CodeableConcept | What was found Binding: ?? (example): Identification of the Condition or diagnosis. | |||||||||||
| itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found | 0..1 | Reference(Condition | Observation | Media) | What was found | |||||||||||
| basis | 0..1 | string | Which investigations support finding | 0..1 | string | Which investigations support finding | |||||||||||
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: ?? (example): Prognosis or outlook findings. | 0..* | CodeableConcept | Estimate of likely outcome Binding: ?? (example): Prognosis or outlook findings. | |||||||||||
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |||||||||||
| supportingInfo | 0..* | Reference(Resource) | Information supporting the clinical impression | 0..* | Reference(Resource) | Information supporting the clinical impression | |||||||||||
| note | 0..* | Annotation | Comments made about the ClinicalImpression | 0..* | Annotation | Comments made about the ClinicalImpression | |||||||||||
| Documentation for this format | |||||||||||||||||