Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam - Draft for Community Review (v0.8.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

• Nội dung narrative
• XML
• JSON
• TTL

: Ví dụ: Nhận định lâm sàng — Tăng huyết áp kiểm soát chưa tốt

Bản thô ttl | Tải xuống

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/ClinicalImpression/ExampleClinicalImpressionHypertension> a fhir:ClinicalImpression ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleClinicalImpressionHypertension"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-clinical-impression>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "vi"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression ExampleClinicalImpressionHypertension</b></p><a name=\"ExampleClinicalImpressionHypertension\"> </a><a name=\"hcExampleClinicalImpressionHypertension\"> </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-clinical-impression.html\">Nhận định lâm sàng VN Core — VN Core ClinicalImpression Profile</a></p></div><p><b>status</b>: Completed</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; identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-03-19-NGT-0207; 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>: 2026-03-19 09:00:00+0700</p><p><b>assessor</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">BS CKII Nguyễn Thị Lan</a></p><p><b>summary</b>: Tăng huyết áp đang dùng Amlodipine 5mg/ngày nhưng HA tại phòng khám 150/95 mmHg — chưa đạt đích &lt; 140/90. Tuân thủ thuốc tốt. Cân nhắc tăng liều hoặc phối hợp thuốc; tư vấn giảm muối, theo dõi HA tại nhà.</p><h3>Findings</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>ItemReference</b></td></tr><tr><td style=\"display: none\">*</td><td><a href=\"Condition-ExampleConditionProblemHypertension.html\">Tăng huyết áp vô căn (I10)</a></td></tr></table></div>"
  ] ;
  fhir:ClinicalImpression.status [ fhir:value "completed"] ;
  fhir:ClinicalImpression.subject [
     fhir:link <http://hl7.org/fhir/Patient/ExamplePatientNguyenVanAn> ;
     fhir:Reference.reference [ fhir:value "Patient/ExamplePatientNguyenVanAn" ] ;
     fhir:Reference.display [ fhir:value "Nguyễn Văn An" ]
  ] ;
  fhir:ClinicalImpression.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/ExampleEncounterOutpatient> ;
     fhir:Reference.reference [ fhir:value "Encounter/ExampleEncounterOutpatient" ]
  ] ;
  fhir:ClinicalImpression.effectiveDateTime [ fhir:value "2026-03-19T09:00:00+07:00"^^xsd:dateTime] ;
  fhir:ClinicalImpression.assessor [
     fhir:link <http://hl7.org/fhir/Practitioner/ExamplePractitionerBSCKII> ;
     fhir:Reference.reference [ fhir:value "Practitioner/ExamplePractitionerBSCKII" ] ;
     fhir:Reference.display [ fhir:value "BS CKII Nguyễn Thị Lan" ]
  ] ;
  fhir:ClinicalImpression.summary [ fhir:value "Tăng huyết áp đang dùng Amlodipine 5mg/ngày nhưng HA tại phòng khám 150/95 mmHg — chưa đạt đích < 140/90. Tuân thủ thuốc tốt. Cân nhắc tăng liều hoặc phối hợp thuốc; tư vấn giảm muối, theo dõi HA tại nhà."] ;
  fhir:ClinicalImpression.finding [
     fhir:index -1 ;
     fhir:ClinicalImpression.finding.itemReference [
       fhir:link <http://hl7.org/fhir/Condition/ExampleConditionProblemHypertension> ;
       fhir:Reference.reference [ fhir:value "Condition/ExampleConditionProblemHypertension" ] ;
       fhir:Reference.display [ fhir:value "Tăng huyết áp vô căn (I10)" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/ExamplePatientNguyenVanAn> a fhir:Patient .

<http://hl7.org/fhir/Encounter/ExampleEncounterOutpatient> a fhir:Encounter .

<http://hl7.org/fhir/Practitioner/ExamplePractitionerBSCKII> a fhir:Practitioner .

<http://hl7.org/fhir/Condition/ExampleConditionProblemHypertension> a fhir:Condition .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ClinicalImpression/ExampleClinicalImpressionHypertension.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/ClinicalImpression/ExampleClinicalImpressionHypertension.ttl> .