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: Sổ Sức khỏe điện tử (Patient Summary) — Nguyễn Văn An

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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/Composition/ExampleCompositionHealthRecordSummary> a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ExampleCompositionHealthRecordSummary"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition-health-record-summary" ;
       fhir:index -1 ;
       fhir:link <http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-composition-health-record-summary>
     ]
  ] ;
  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\"><h1>Sổ Sức khỏe điện tử — Nguyễn Văn An</h1><p>Tóm tắt: Tăng huyết áp, Đái tháo đường type 2. Dị ứng Penicillin. Đang điều trị Amlodipine. Phân loại sức khỏe gần nhất: Loại II.</p></div>"
  ] ;
  fhir:Composition.status [ fhir:value "final"] ;
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       a loinc:60591-5 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "60591-5" ] ;
       fhir:Coding.display [ fhir:value "Patient summary Document" ]
     ]
  ] ;
  fhir:Composition.subject [
     fhir:link <http://hl7.org/fhir/Patient/ExamplePatientNguyenVanAn> ;
     fhir:Reference.reference [ fhir:value "Patient/ExamplePatientNguyenVanAn" ]
  ] ;
  fhir:Composition.date [ fhir:value "2026-06-02T08:00:00+07:00"^^xsd:dateTime] ;
  fhir:Composition.author [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Organization/ExampleOrganizationHealthCheckupFacility> ;
     fhir:Reference.reference [ fhir:value "Organization/ExampleOrganizationHealthCheckupFacility" ]
  ] ;
  fhir:Composition.title [ fhir:value "Sổ Sức khỏe điện tử"] ;
  fhir:Composition.attester [
     fhir:index -1 ;
     fhir:Composition.attester.mode [ fhir:value "legal" ] ;
     fhir:Composition.attester.party [
       fhir:link <http://hl7.org/fhir/Organization/ExampleOrganizationHealthCheckupFacility> ;
       fhir:Reference.reference [ fhir:value "Organization/ExampleOrganizationHealthCheckupFacility" ]
     ]
  ] ;
  fhir:Composition.custodian [
     fhir:link <http://hl7.org/fhir/Organization/ExampleOrganizationHealthCheckupFacility> ;
     fhir:Reference.reference [ fhir:value "Organization/ExampleOrganizationHealthCheckupFacility" ]
  ] ;
  fhir:Composition.section [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Tiền sử dị ứng" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:48765-2 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "48765-2" ] ;
         fhir:Coding.display [ fhir:value "Allergies and adverse reactions Document" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/AllergyIntolerance/ExampleAllergyPenicillin> ;
       fhir:Reference.reference [ fhir:value "AllergyIntolerance/ExampleAllergyPenicillin" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Tiền sử bệnh tật" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:11450-4 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "11450-4" ] ;
         fhir:Coding.display [ fhir:value "Problem list - Reported" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Condition/ExampleConditionProblemHypertension> ;
       fhir:Reference.reference [ fhir:value "Condition/ExampleConditionProblemHypertension" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Condition/ExampleConditionDiabetes> ;
       fhir:Reference.reference [ fhir:value "Condition/ExampleConditionDiabetes" ]
     ]
  ], [
     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.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/MedicationRequest/ExampleMedicationRequestHypertension> ;
       fhir:Reference.reference [ fhir:value "MedicationRequest/ExampleMedicationRequestHypertension" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Tiền sử tiêm chủng" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:11369-6 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "11369-6" ] ;
         fhir:Coding.display [ fhir:value "History of Immunization note" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Immunization/ExampleImmunizationTCMR> ;
       fhir:Reference.reference [ fhir:value "Immunization/ExampleImmunizationTCMR" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Kết quả xét nghiệm" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:30954-2 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "30954-2" ] ;
         fhir:Coding.display [ fhir:value "Relevant diagnostic tests/laboratory data note" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/ExampleObservationLabGlucose> ;
       fhir:Reference.reference [ fhir:value "Observation/ExampleObservationLabGlucose" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/ExampleObservationLabHbA1c> ;
       fhir:Reference.reference [ fhir:value "Observation/ExampleObservationLabHbA1c" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Phẫu thuật, thủ thuật" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:47519-4 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "47519-4" ] ;
         fhir:Coding.display [ fhir:value "History of Procedures Document" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Procedure/ExampleProcedureAppendectomy> ;
       fhir:Reference.reference [ fhir:value "Procedure/ExampleProcedureAppendectomy" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Chỉ số theo dõi chính" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:8716-3 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "8716-3" ] ;
         fhir:Coding.display [ fhir:value "Vital signs note" ]
       ]
     ] ;
     fhir:Composition.section.entry [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/ExampleObservationVitalBP> ;
       fhir:Reference.reference [ fhir:value "Observation/ExampleObservationVitalBP" ]
     ], [
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/Observation/ExampleObservationVitalBMI> ;
       fhir:Reference.reference [ fhir:value "Observation/ExampleObservationVitalBMI" ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Composition.section.title [ fhir:value "Khám sức khỏe định kỳ" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         a loinc:34117-2 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "34117-2" ] ;
         fhir:Coding.display [ fhir:value "History and physical note" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "generated" ] ;
       fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Khám sức khỏe định kỳ gần nhất: phân loại sức khỏe Loại I (Rất khoẻ). Hồ sơ Khám sức khỏe đầy đủ được lưu dưới dạng tài liệu KSK riêng (VNCoreCompositionHealthCheckup).</div>"
     ]
  ] .

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

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

<http://hl7.org/fhir/AllergyIntolerance/ExampleAllergyPenicillin> a fhir:AllergyIntolerance .

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

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

<http://hl7.org/fhir/MedicationRequest/ExampleMedicationRequestHypertension> a fhir:MedicationRequest .

<http://hl7.org/fhir/Immunization/ExampleImmunizationTCMR> a fhir:Immunization .

<http://hl7.org/fhir/Observation/ExampleObservationLabGlucose> a fhir:Observation .

<http://hl7.org/fhir/Observation/ExampleObservationLabHbA1c> a fhir:Observation .

<http://hl7.org/fhir/Procedure/ExampleProcedureAppendectomy> a fhir:Procedure .

<http://hl7.org/fhir/Observation/ExampleObservationVitalBP> a fhir:Observation .

<http://hl7.org/fhir/Observation/ExampleObservationVitalBMI> a fhir:Observation .

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

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