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: Báo cáo giải phẫu bệnh — Viêm ruột thừa cấp mủ

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 sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

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

<http://hl7.org/fhir/DiagnosticReport/ExampleDiagnosticReportPathology> a fhir:DiagnosticReport ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleDiagnosticReportPathology"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report-pathology" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-diagnostic-report-pathology>
     ]
  ] ;
  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: DiagnosticReport ExampleDiagnosticReportPathology</b></p><a name=\"ExampleDiagnosticReportPathology\"> </a><a name=\"hcExampleDiagnosticReportPathology\"> </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-diagnostic-report-pathology.html\">Báo cáo Giải phẫu bệnh VN Core — VN Core Pathology DiagnosticReport</a></p></div><h2><span title=\"Codes:{http://loinc.org 60568-3}\">Giải phẫu bệnh lý</span> (<span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0074 SP}\">Surgical Pathology</span>, <span title=\"Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs 3}\">Xét nghiệm</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Nguyễn Văn An Male, DoB: 1985-03-15 ( Căn cước công dân: VNCCCD#001085012345)</td></tr><tr><td>Relevant Time</td><td>2026-03-10 14:30:00+0700</td></tr><tr><td>Reported</td><td>2026-03-12 16:00:00+0700</td></tr><tr><td>Performer</td><td> <a href=\"Organization-ExampleOrganizationChoRay.html\">Khoa Giải phẫu bệnh — BV Chợ Rẫy</a></td></tr></table><p><b>Report Details</b></p><p>Đại thể: Ruột thừa dài 7cm, đường kính 1.2cm, sưng nề phù nề, phủ fibrin màu vàng xanh. Lòng ruột thừa chứa mủ vàng đục. Vi thể: Thâm nhập bạch cầu đa nhân toàn thành, mủ trong lòng ruột thừa. Hoại tử thành khu trú, chưa thủng. Không thấy tế bào ác tính. Kết luận: Viêm ruột thừa cấp mủ (K35.8), chưa vỡ.</p><p><b>Coded Conclusions:</b></p><ul><li><span title=\"Codes:{http://snomed.info/sct 45959006}, {http://hl7.org/fhir/sid/icd-10 K35.8}\">Viêm ruột thừa cấp mủ, chưa vỡ</span></li></ul></div>"
  ] ;
  fhir:DiagnosticReport.status [ fhir:value "final"] ;
  fhir:DiagnosticReport.category [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0074" ] ;
       fhir:Coding.code [ fhir:value "SP" ] ;
       fhir:Coding.display [ fhir:value "Surgical Pathology" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://fhir.hl7.org.vn/core/CodeSystem/vn-cost-category-cs" ] ;
       fhir:Coding.code [ fhir:value "3" ] ;
       fhir:Coding.display [ fhir:value "Xét nghiệm" ]
     ]
  ] ;
  fhir:DiagnosticReport.code [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:60568-3 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "60568-3" ] ;
       fhir:Coding.display [ fhir:value "Pathology synoptic report" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Giải phẫu bệnh lý" ]
  ] ;
  fhir:DiagnosticReport.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:DiagnosticReport.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/ExampleEncounterInpatient> ;
     fhir:Reference.reference [ fhir:value "Encounter/ExampleEncounterInpatient" ]
  ] ;
  fhir:DiagnosticReport.effectiveDateTime [ fhir:value "2026-03-10T14:30:00+07:00"^^xsd:dateTime] ;
  fhir:DiagnosticReport.issued [ fhir:value "2026-03-12T16:00:00+07:00"^^xsd:dateTime] ;
  fhir:DiagnosticReport.performer [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Organization/ExampleOrganizationChoRay> ;
     fhir:Reference.reference [ fhir:value "Organization/ExampleOrganizationChoRay" ] ;
     fhir:Reference.display [ fhir:value "Khoa Giải phẫu bệnh — BV Chợ Rẫy" ]
  ] ;
  fhir:DiagnosticReport.specimen [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Specimen/ExampleSpecimenAppendixTissue> ;
     fhir:Reference.reference [ fhir:value "Specimen/ExampleSpecimenAppendixTissue" ] ;
     fhir:Reference.display [ fhir:value "Mẫu mô ruột thừa sau cắt ruột thừa" ]
  ] ;
  fhir:DiagnosticReport.conclusion [ fhir:value "Đại thể: Ruột thừa dài 7cm, đường kính 1.2cm, sưng nề phù nề, phủ fibrin màu vàng xanh. Lòng ruột thừa chứa mủ vàng đục. Vi thể: Thâm nhập bạch cầu đa nhân toàn thành, mủ trong lòng ruột thừa. Hoại tử thành khu trú, chưa thủng. Không thấy tế bào ác tính. Kết luận: Viêm ruột thừa cấp mủ (K35.8), chưa vỡ."] ;
  fhir:DiagnosticReport.conclusionCode [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a sct:45959006 ;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ;
       fhir:Coding.code [ fhir:value "45959006" ] ;
       fhir:Coding.display [ fhir:value "Acute suppurative inflammation" ]
     ], [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10" ] ;
       fhir:Coding.code [ fhir:value "K35.8" ] ;
       fhir:Coding.display [ fhir:value "Acute appendicitis, other and unspecified" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Viêm ruột thừa cấp mủ, chưa vỡ" ]
  ] ;
  fhir:DiagnosticReport.presentedForm [
     fhir:index -1 ;
     fhir:Attachment.contentType [ fhir:value "application/pdf" ] ;
     fhir:Attachment.language [ fhir:value "vi" ] ;
     fhir:Attachment.title [ fhir:value "GPB-RuotThua-NguyenVanAn-20260312.pdf" ] ;
     fhir:Attachment.creation [ fhir:value "2026-03-12T16:00:00+07:00"^^xsd:dateTime ]
  ] .

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

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

<http://hl7.org/fhir/Organization/ExampleOrganizationChoRay> a fhir:Organization .

<http://hl7.org/fhir/Specimen/ExampleSpecimenAppendixTissue> a fhir:Specimen .

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

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