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: Đánh giá YHCT — Thiết chẩn mạch và vọng chẩn lưỡi

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

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

<http://hl7.org/fhir/Observation/ExampleObservationYHCTPulse> a fhir:Observation ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleObservationYHCTPulse"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-yhct" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-observation-yhct>
     ]
  ] ;
  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 ExampleObservationYHCTPulse</b></p><a name=\"ExampleObservationYHCTPulse\"> </a><a name=\"hcExampleObservationYHCTPulse\"> </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-yhct.html\">Đánh giá YHCT VN Core — VN Core Observation Traditional Medicine Profile</a></p></div><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs YHCT}\">Y học cổ truyền</span></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 5880005}\">Thiết chẩn mạch — Bắt mạch YHCT</span></p><p><b>subject</b>: <a href=\"Patient-ExamplePatientNguyenVanAn.html\">Nguyễn Văn An</a></p><p><b>encounter</b>: <a href=\"Encounter-ExampleEncounterYHCT.html\">Encounter: extension = Khám chữa bệnh ban đầu,Đến khám,Đỡ; identifier = Mã lượt khám chữa bệnh: VNMaLuotKCB#LK-2026-03-22-0087; status = finished; class = ambulatory (ActCode#AMB); type = Khám bệnh; period = 2026-03-22 08:00:00+0700 --&gt; 2026-03-22 10:30:00+0700; reasonCode = </a></p><p><b>effective</b>: 2026-03-22 09:30:00+0700</p><p><b>performer</b>: <a href=\"Practitioner-ExamplePractitionerBSCKII.html\">BS. Nguyễn Thị Lan</a></p><p><b>value</b>: Mạch trầm, trì. Lưỡi nhợt, rêu trắng. Phù hợp thể hàn thấp.</p><p><b>note</b>: </p><blockquote><div><p>Bệnh nhân đến khám do đau lưng 1 tuần, tăng khi trời lạnh. Tứ chẩn: Vọng — lưỡi nhợt rêu trắng; Thiết — mạch trầm trì. Nhận định: thể hàn thấp. Đề xuất: sơ phong tán hàn, trừ thấp chỉ thống.</p>\n</div></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-pulse-cs 6581102}\">Mạch trầm</span></p><p><b>value</b>: Mạch trầm (Deep pulse) — cả hai tay, rõ nhất là bộ thận</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-tongue-cs 6581007}\">Chất lưỡi nhợt/Chất lưỡi nhạt</span></p><p><b>value</b>: Chất lưỡi nhợt, bèo — biểu hiện hàn thấp</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-symptom-cs 6541000}\">Đau nhiều vùng thắt lưng</span></p><p><b>value</b>: Đau tăng khi trời lạnh, ẩm. Có cạnh cột sống co cứng.</p></blockquote></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://fhir.hl7.org.vn/core/CodeSystem/vn-service-request-category-cs" ] ;
       fhir:Coding.code [ fhir:value "YHCT" ] ;
       fhir:Coding.display [ fhir:value "Y học cổ truyền" ]
     ]
  ] ;
  fhir:Observation.code [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a sct:5880005 ;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ;
       fhir:Coding.code [ fhir:value "5880005" ] ;
       fhir:Coding.display [ fhir:value "Clinical examination" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Thiết chẩn mạch — Bắt mạch YHCT" ]
  ] ;
  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/ExampleEncounterYHCT> ;
     fhir:Reference.reference [ fhir:value "Encounter/ExampleEncounterYHCT" ]
  ] ;
  fhir:Observation.effectiveDateTime [ fhir:value "2026-03-22T09:30:00+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. Nguyễn Thị Lan" ]
  ] ;
  fhir:Observation.valueString [ fhir:value "Mạch trầm, trì. Lưỡi nhợt, rêu trắng. Phù hợp thể hàn thấp."] ;
  fhir:Observation.note [
     fhir:index -1 ;
     fhir:Annotation.text [ fhir:value "Bệnh nhân đến khám do đau lưng 1 tuần, tăng khi trời lạnh. Tứ chẩn: Vọng — lưỡi nhợt rêu trắng; Thiết — mạch trầm trì. Nhận định: thể hàn thấp. Đề xuất: sơ phong tán hàn, trừ thấp chỉ thống." ]
  ] ;
  fhir:Observation.component [
     fhir:index -1 ;
     fhir:Observation.component.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-pulse-cs" ] ;
         fhir:Coding.code [ fhir:value "6581102" ] ;
         fhir:Coding.display [ fhir:value "Mạch trầm" ]
       ]
     ] ;
     fhir:Observation.component.valueString [ fhir:value "Mạch trầm (Deep pulse) — cả hai tay, rõ nhất là bộ thận" ]
  ], [
     fhir:index -1 ;
     fhir:Observation.component.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-tongue-cs" ] ;
         fhir:Coding.code [ fhir:value "6581007" ] ;
         fhir:Coding.display [ fhir:value "Chất lưỡi nhợt/Chất lưỡi nhạt" ]
       ]
     ] ;
     fhir:Observation.component.valueString [ fhir:value "Chất lưỡi nhợt, bèo — biểu hiện hàn thấp" ]
  ], [
     fhir:index -1 ;
     fhir:Observation.component.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "http://fhir.hl7.org.vn/core/CodeSystem/vn-yhct-symptom-cs" ] ;
         fhir:Coding.code [ fhir:value "6541000" ] ;
         fhir:Coding.display [ fhir:value "Đau nhiều vùng thắt lưng" ]
       ]
     ] ;
     fhir:Observation.component.valueString [ fhir:value "Đau tăng khi trời lạnh, ẩm. Có cạnh cột sống co cứng." ]
  ] .

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

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

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

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

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