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: Creatinine huyết thanh — Theo dõi chức năng thận

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@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/Observation/ExampleObservationLabCreatinine> a fhir:Observation ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleObservationLabCreatinine"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-lab>
     ]
  ] ;
  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: Observation ExampleObservationLabCreatinine</b></p><a name=\"ExampleObservationLabCreatinine\"> </a><a name=\"hcExampleObservationLabCreatinine\"> </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-observation-lab.html\">Xét nghiệm VN Core — VN Core Observation Laboratory Profile</a></p></div><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 2160-0}\">Creatinine huyết thanh</span></p><p><b>subject</b>: <a href=\"Patient-ExamplePatientNguyenVanAn.html\">Nguyễn Văn An</a></p><p><b>encounter</b>: <a href=\"Encounter-ExampleEncounterEmergency.html\">Encounter: extension = Cấp cứu,Cấp cứu,Đỡ; identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-04-20-CC-0015; status = finished; class = emergency (ActCode#EMER); type = Khám bệnh; period = 2026-04-20 20:30:00+0700 --&gt; 2026-04-21 06:00:00+0700; reasonCode = </a></p><p><b>effective</b>: 2026-04-20 08:30:00+0700</p><p><b>performer</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">BS CKII Nguyễn Thị Lan</a></p><p><b>value</b>: 142 µmol/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeumol/L = 'umol/L')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><p><b>note</b>: </p><blockquote><div><p>Creatinine tăng 142 µmol/L — eGFR ước tính ~52 mL/phút/1.73m² (CKD giai đoạn 3a theo phân loại KDIGO 2024). Cần theo dõi chức năng thận định kỳ mỗi 3 tháng, xét nghiệm bổ sung: Protein niệu 24h / ACR, siêu âm thận. Cân nhắc giảm liều hoặc ngưng các thuốc thải qua thận (đặc biệt Metformin khi eGFR &lt; 45). Hội chẩn chuyên khoa Thận học nếu eGFR &lt; 45 hoặc có diễn tiến nhanh.</p>\n</div></blockquote><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td><td><b>Text</b></td></tr><tr><td style=\"display: none\">*</td><td>62 µmol/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeumol/L = 'umol/L')</span></td><td>106 µmol/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeumol/L = 'umol/L')</span></td><td>62 – 106 µmol/L (nam)</td></tr></table></div>"
  ] ;
  fhir:Observation.status [ fhir:value "final"] ;
  fhir:Observation.category [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/observation-category" ] ;
       fhir:Coding.code [ fhir:value "laboratory" ] ;
       fhir:Coding.display [ fhir:value "Laboratory" ]
     ]
  ] ;
  fhir:Observation.code [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:2160-0 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "2160-0" ] ;
       fhir:Coding.display [ fhir:value "Creatinine [Mass/volume] in Serum or Plasma" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Creatinine huyết thanh" ]
  ] ;
  fhir:Observation.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:Observation.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/ExampleEncounterEmergency> ;
     fhir:Reference.reference [ fhir:value "Encounter/ExampleEncounterEmergency" ]
  ] ;
  fhir:Observation.effectiveDateTime [ fhir:value "2026-04-20T08:30:00+07:00"^^xsd:dateTime] ;
  fhir:Observation.performer [
     fhir:index -1 ;
     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:Observation.valueQuantity [
     fhir:Quantity.value [ fhir:value "142"^^xsd:decimal ] ;
     fhir:Quantity.unit [ fhir:value "µmol/L" ] ;
     fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
     fhir:Quantity.code [ fhir:value "umol/L" ]
  ] ;
  fhir:Observation.interpretation [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation" ] ;
       fhir:Coding.code [ fhir:value "H" ] ;
       fhir:Coding.display [ fhir:value "High" ]
     ]
  ] ;
  fhir:Observation.note [
     fhir:index -1 ;
     fhir:Annotation.text [ fhir:value "Creatinine tăng 142 µmol/L — eGFR ước tính ~52 mL/phút/1.73m² (CKD giai đoạn 3a theo phân loại KDIGO 2024). Cần theo dõi chức năng thận định kỳ mỗi 3 tháng, xét nghiệm bổ sung: Protein niệu 24h / ACR, siêu âm thận. Cân nhắc giảm liều hoặc ngưng các thuốc thải qua thận (đặc biệt Metformin khi eGFR < 45). Hội chẩn chuyên khoa Thận học nếu eGFR < 45 hoặc có diễn tiến nhanh." ]
  ] ;
  fhir:Observation.referenceRange [
     fhir:index -1 ;
     fhir:Observation.referenceRange.low [
       fhir:Quantity.value [ fhir:value "62"^^xsd:decimal ] ;
       fhir:Quantity.unit [ fhir:value "µmol/L" ] ;
       fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
       fhir:Quantity.code [ fhir:value "umol/L" ]
     ] ;
     fhir:Observation.referenceRange.high [
       fhir:Quantity.value [ fhir:value "106"^^xsd:decimal ] ;
       fhir:Quantity.unit [ fhir:value "µmol/L" ] ;
       fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
       fhir:Quantity.code [ fhir:value "umol/L" ]
     ] ;
     fhir:Observation.referenceRange.text [ fhir:value "62 – 106 µmol/L (nam)" ]
  ] .

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

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

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

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

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