HL7 Vietnam VN Core FHIR Implementation Guide

Bộ Hướng dẫn Triển khai Core FHIR cho Việt Nam
0.8.0 - Draft for Community Review Viet Nam cờ

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

: Ví dụ — Bệnh án ngoại trú (viêm phổi)

Bản thô ttl | Tải xuống


@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@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/Composition/ExampleCompositionEMR> a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleCompositionEMR"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition>
     ]
  ] ;
  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: Composition ExampleCompositionEMR</b></p><a name=\"ExampleCompositionEMR\"> </a><a name=\"hcExampleCompositionEMR\"> </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-composition.html\">Bệnh án điện tử VN Core — VN Core Composition Profile</a></p></div><p><b>identifier</b>: <a href=\"NamingSystem-vn-document-number-ns.html\" title=\"SCHEME DÙNG TẠM per-facility — 0.8.0 hạ cấp (hậu kiểm toán Codex): định danh này do TỪNG cơ sở#xA;tự quản lý nên khóa uniqueness là system+value; một URI quốc gia dùng chung KHÔNG bảo đảm uniqueness.#xA;Khuyến nghị chính: mỗi cơ sở tự công bố URI riêng; URI scheme này chỉ dùng khi chưa có URI riêng,#xA;khi đó assigner là bắt buộc nghiệp vụ (khuyến nghị bổ sung, không phải cơ chế uniqueness chính).#xA;Namespace khuyến nghị cho mã tài liệu lâm sàng nội bộ do cơ sở y tế phát sinh, dùng cho Composition.identifier và DocumentReference.identifier khi chưa có NamingSystem riêng của từng cơ sở.\">VNDocumentNumber</a>/BA-2026-00451</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 34108-1}\">Outpatient Note</span></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>date</b>: 2026-03-19 09:30:00+0700</p><p><b>author</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">Practitioner Nguyễn Thị Lan</a></p><p><b>title</b>: Bệnh án ngoại trú</p><p><b>confidentiality</b>: restricted</p><p><b>custodian</b>: <a href=\"Organization-ExampleOrganizationChoRay.html\">Organization Bệnh viện Chợ Rẫy</a></p></div>"
  ] ;
  fhir:Composition.identifier [
     fhir:Identifier.system [ fhir:value "http://fhir.hl7.org.vn/core/sid/document-number" ] ;
     fhir:Identifier.value [ fhir:value "BA-2026-00451" ]
  ] ;
  fhir:Composition.status [ fhir:value "final"] ;
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:34108-1 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "34108-1" ] ;
       fhir:Coding.display [ fhir:value "Outpatient Note" ]
     ]
  ] ;
  fhir:Composition.subject [
     fhir:link <http://hl7.org/fhir/Patient/ExamplePatientNguyenVanAn> ;
     fhir:Reference.reference [ fhir:value "Patient/ExamplePatientNguyenVanAn" ]
  ] ;
  fhir:Composition.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/ExampleEncounterOutpatient> ;
     fhir:Reference.reference [ fhir:value "Encounter/ExampleEncounterOutpatient" ]
  ] ;
  fhir:Composition.date [ fhir:value "2026-03-19T09:30:00+07:00"^^xsd:dateTime] ;
  fhir:Composition.author [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Practitioner/ExamplePractitionerBSCKII> ;
     fhir:Reference.reference [ fhir:value "Practitioner/ExamplePractitionerBSCKII" ]
  ] ;
  fhir:Composition.title [ fhir:value "Bệnh án ngoại trú"] ;
  fhir:Composition.confidentiality [ fhir:value "R"] ;
  fhir:Composition.custodian [
     fhir:link <http://hl7.org/fhir/Organization/ExampleOrganizationChoRay> ;
     fhir:Reference.reference [ fhir:value "Organization/ExampleOrganizationChoRay" ]
  ] ;
  fhir:Composition.section [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Lý do đến khám" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:10154-3 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "10154-3" ] ;
         fhir:Coding.display [ fhir:value "Chief complaint Narrative - Reported" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ] ;
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Sốt, ho có đờm, khó thở nhẹ 3 ngày. Tiền sử tăng huyết áp và đái tháo đường type 2 đang điều trị.</div>"
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Chẩn đoán" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:29548-5 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "29548-5" ] ;
         fhir:Coding.display [ fhir:value "Diagnosis Narrative" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ] ;
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Viêm phổi, không xác định tác nhân (J18.9 — ICD-10 VN theo QĐ 4469/QĐ-BYT). Bệnh kèm: Đái tháo đường type 2 (E11.9), Tăng huyết áp nguyên phát (I10) — tiền sử đang điều trị.</div>"
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Thuốc điều trị" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:10160-0 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "10160-0" ] ;
         fhir:Coding.display [ fhir:value "History of Medication use Narrative" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ] ;
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Amoxicillin 500mg x 3 lần/ngày, uống sau ăn, 7 ngày. Paracetamol 500mg khi sốt. Duy trì Amlodipine 5mg/ngày cho tăng huyết áp. Tái khám sau 1 tuần hoặc khi khó thở tăng.</div>"
     ]
  ] .

<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/Organization/ExampleOrganizationChoRay> a fhir:Organization .

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

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