{ "resourceType": "StructureDefinition", "id": "vn-core-documentreference", "url": "http://fhir.ironx.io.vn/StructureDefinition/vn-core-documentreference", "version": "1.0.0", "name": "VNCoreDocumentreference", "title": "VN Core Documentreference (Profile)", "status": "active", "experimental": false, "date": "2025-09-21T20:19:12+00:00", "publisher": "IronX", "description": "Hồ sơ này định nghĩa các ràng buộc và mở rộng cho DocumentReference để sử dụng trong hệ thống y tế Việt Nam. Tài liệu có thể là tài liệu lâm sàng (như bệnh án, kết quả xét nghiệm), tài liệu hành chính (như giấy ra viện, đơn thuốc), hoặc các tài liệu khác liên quan đến chăm sóc sức khỏe. Hồ sơ này tuân thủ theo đặc tả FHIR R4 và được điều chỉnh cho phù hợp với bối cảnh Việt Nam.", "fhirVersion": "4.0.1", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern" }, { "identity": "fhircomposition", "uri": "http://hl7.org/fhir/composition", "name": "FHIR Composition" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "cda", "uri": "http://hl7.org/v3/cda", "name": "CDA (R2)" }, { "identity": "w5", "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "xds", "uri": "http://ihe.net/xds", "name": "XDS metadata equivalent" } ], "kind": "resource", "abstract": false, "type": "DocumentReference", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DocumentReference", "derivation": "constraint", "snapshot": { "element": [ { "id": "DocumentReference", "path": "DocumentReference", "short": "Tham chiếu tới tài liệu điện tử", "definition": "Tham chiếu và siêu dữ liệu về một tài liệu của bất kỳ loại nào cho mục đích lâm sàng, hành chính hoặc bằng chứng chất lượng. Đây có thể là tài liệu đã được số hóa hoặc tài liệu gốc điện tử.", "comment": "Usually, this is used for documents other than those defined by FHIR.", "min": 0, "max": "*", "base": { "path": "DocumentReference", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource", "expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()", "xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:security))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "xpath": "exists(f:text/h:div)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" } ], "mustSupport": false, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "fhircomposition", "map": "when describing a Composition" }, { "identity": "rim", "map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]" }, { "identity": "cda", "map": "when describing a CDA" } ] }, { "id": "DocumentReference.id", "path": "DocumentReference.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "code": "http://hl7.org/fhirpath/System.String", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ] } ], "isModifier": false, "isSummary": true }, { "id": "DocumentReference.meta", "path": "DocumentReference.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true }, { "id": "DocumentReference.implicitRules", "path": "DocumentReference.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.", "comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation", "isSummary": true }, { "id": "DocumentReference.language", "path": "DocumentReference.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "preferred", "description": "A human language.", "valueSet": "http://hl7.org/fhir/ValueSet/languages" } }, { "id": "DocumentReference.text", "path": "DocumentReference.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "id": "DocumentReference.contained", "path": "DocumentReference.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.extension", "path": "DocumentReference.extension", "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.modifierExtension", "path": "DocumentReference.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "isSummary": false, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.masterIdentifier", "path": "DocumentReference.masterIdentifier", "short": "Master Version Specific Identifier", "definition": "Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.", "comment": "CDA Document Id extension and root.", "requirements": "The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form \"oid^extension\", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).", "min": 0, "max": "1", "base": { "path": "DocumentReference.masterIdentifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "fhircomposition", "map": "Composition.identifier" }, { "identity": "v2", "map": "TXA-12" }, { "identity": "rim", "map": ".id" }, { "identity": "xds", "map": "DocumentEntry.uniqueId" }, { "identity": "cda", "map": "ClinicalDocument/id" } ] }, { "id": "DocumentReference.identifier", "path": "DocumentReference.identifier", "short": "Mã định danh tài liệu", "definition": "Mã định danh duy nhất của tài liệu trong hệ thống. Có thể là mã số hồ sơ bệnh án, số phiếu xét nghiệm, số đơn thuốc, v.v.", "comment": "Nên sử dụng hệ thống định danh thống nhất trong tổ chức. Ví dụ: BA{năm}{số_thứ_tự} cho bệnh án, XN{năm}{số_thứ_tự} cho phiếu xét nghiệm.", "min": 0, "max": "*", "base": { "path": "DocumentReference.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "TXA-16?" }, { "identity": "rim", "map": ".id / .setId" }, { "identity": "xds", "map": "DocumentEntry.entryUUID" } ] }, { "id": "DocumentReference.status", "path": "DocumentReference.status", "short": "Trạng thái của tài liệu", "definition": "Trạng thái hiện tại của tài liệu tham chiếu. Có thể là: current (hiện hành), superseded (đã được thay thế), entered-in-error (nhập sai).", "comment": "This is the status of the DocumentReference object, which might be independent from the docStatus element.\n\nThis element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.", "min": 1, "max": "1", "base": { "path": "DocumentReference.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": true, "isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid", "isSummary": true, "binding": { "strength": "required", "valueSet": "http://hl7.org/fhir/ValueSet/document-reference-status" }, "mapping": [ { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "v2", "map": "TXA-19" }, { "identity": "rim", "map": "interim: .completionCode=\"IN\" & ./statusCode[isNormalDatatype()]=\"active\"; final: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and not(./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct()]); amended: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and ./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct() and statusCode=\"completed\"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]=\"obsolete\"" }, { "identity": "xds", "map": "DocumentEntry.availabilityStatus" } ] }, { "id": "DocumentReference.docStatus", "path": "DocumentReference.docStatus", "short": "preliminary | final | amended | entered-in-error", "definition": "The status of the underlying document.", "comment": "The document that is pointed to might be in various lifecycle states.", "min": 0, "max": "1", "base": { "path": "DocumentReference.docStatus", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ReferredDocumentStatus" } ], "strength": "required", "description": "Status of the underlying document.", "valueSet": "http://hl7.org/fhir/ValueSet/composition-status|4.0.1" }, "mapping": [ { "identity": "w5", "map": "FiveWs.status" }, { "identity": "fhircomposition", "map": "Composition.status" }, { "identity": "v2", "map": "TXA-17" }, { "identity": "rim", "map": ".statusCode" } ] }, { "id": "DocumentReference.type", "path": "DocumentReference.type", "short": "Loại tài liệu", "definition": "Loại cụ thể của tài liệu (ví dụ: bệnh án, đơn thuốc, phiếu xét nghiệm, v.v.)", "comment": "Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.", "min": 1, "max": "1", "base": { "path": "DocumentReference.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80Type" } ], "strength": "preferred", "description": "Precise type of clinical document.", "valueSet": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes" }, "mapping": [ { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "fhircomposition", "map": "Composition.type" }, { "identity": "v2", "map": "TXA-2" }, { "identity": "rim", "map": "./code" }, { "identity": "xds", "map": "DocumentEntry.type" }, { "identity": "cda", "map": "ClinicalDocument/code/@code \n\nThe typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted." } ] }, { "id": "DocumentReference.category", "path": "DocumentReference.category", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "short": "Categorization of document", "definition": "A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.", "comment": "Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.", "alias": [ "claxs" ], "min": 1, "max": "*", "base": { "path": "DocumentReference.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80Class" } ], "strength": "example", "description": "High-level kind of a clinical document at a macro level.", "valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes" }, "mapping": [ { "identity": "w5", "map": "FiveWs.class" }, { "identity": "fhircomposition", "map": "Composition.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" }, { "identity": "xds", "map": "DocumentEntry.class" }, { "identity": "cda", "map": "Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code" } ] }, { "id": "DocumentReference.category:vncore", "path": "DocumentReference.category", "sliceName": "vncore", "short": "Phân loại tài liệu (VN Core)", "definition": "A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.", "comment": "Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.", "alias": [ "claxs" ], "min": 0, "max": "*", "base": { "path": "DocumentReference.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80Class" } ], "strength": "example", "description": "High-level kind of a clinical document at a macro level.", "valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes" }, "mapping": [ { "identity": "w5", "map": "FiveWs.class" }, { "identity": "fhircomposition", "map": "Composition.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" }, { "identity": "xds", "map": "DocumentEntry.class" }, { "identity": "cda", "map": "Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code" } ] }, { "id": "DocumentReference.subject", "path": "DocumentReference.subject", "short": "Đối tượng được đề cập trong tài liệu", "definition": "Đối tượng chính mà tài liệu đề cập đến. Thông thường là bệnh nhân, nhưng cũng có thể là nhân viên y tế (trong trường hợp tài liệu về nhân sự), thiết bị (trong trường hợp tài liệu kỹ thuật), hoặc nhóm bệnh nhân (trong trường hợp báo cáo nhóm).", "comment": "Trường này bắt buộc phải có và thường tham chiếu đến Patient. Trong một số trường hợp đặc biệt có thể tham chiếu đến các đối tượng khác như Practitioner, Device hoặc Group tùy theo nội dung tài liệu.", "min": 1, "max": "1", "base": { "path": "DocumentReference.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-patient", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-group", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-device" ], "_targetProfile": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": true } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] } ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "fhircomposition", "map": "Composition.subject" }, { "identity": "v2", "map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]" }, { "identity": "xds", "map": "DocumentEntry.patientId" }, { "identity": "cda", "map": "ClinicalDocument/recordTarget/" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "DocumentReference.date", "path": "DocumentReference.date", "short": "Thời điểm tạo DocumentReference", "definition": "Thời điểm tạo bản ghi DocumentReference này trên hệ thống, không phải thời điểm tạo tài liệu gốc. Thời điểm tạo tài liệu gốc được lưu trong DocumentReference.content.attachment.creation. Trường này có thể dùng để theo dõi thời điểm số hóa tài liệu giấy hoặc thời điểm nhập tài liệu vào hệ thống.", "comment": "Đây là thời điểm metadata về tài liệu được tạo ra, khác với thời điểm tạo ra nội dung tài liệu. Ví dụ: một bệnh án được viết ngày 01/01/2025 (DocumentReference.content.attachment.creation) nhưng được scan và tạo DocumentReference vào ngày 15/01/2025 (DocumentReference.date).", "alias": [ "indexed" ], "min": 0, "max": "1", "base": { "path": "DocumentReference.date", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "fhircomposition", "map": "Composition.date" }, { "identity": "rim", "map": ".availabilityTime[type=\"TS\"]" } ] }, { "id": "DocumentReference.author", "path": "DocumentReference.author", "short": "Người/tổ chức tạo ra tài liệu", "definition": "Người hoặc tổ chức chịu trách nhiệm chính về nội dung của tài liệu. Ví dụ: bác sĩ viết bệnh án, kỹ thuật viên thực hiện xét nghiệm, hoặc bệnh nhân trong trường hợp tự ghi chép.", "comment": "Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).", "min": 0, "max": "*", "base": { "path": "DocumentReference.author", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-patient", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitionerrole", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-relatedperson", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-device" ], "_targetProfile": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": true } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] } ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.author" }, { "identity": "v2", "map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.author" }, { "identity": "cda", "map": "ClinicalDocument/author" } ] }, { "id": "DocumentReference.authenticator", "path": "DocumentReference.authenticator", "short": "Người xác thực tài liệu", "definition": "Người có thẩm quyền xác thực tính chính xác và hợp pháp của tài liệu. Ví dụ: Trưởng khoa ký bệnh án, Giám đốc bệnh viện ký giấy ra viện.", "comment": "Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.", "min": 0, "max": "1", "base": { "path": "DocumentReference.authenticator", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitionerrole", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.witness" }, { "identity": "fhircomposition", "map": "Composition.attester" }, { "identity": "v2", "map": "TXA-10" }, { "identity": "rim", "map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.legalAuthenticator" }, { "identity": "cda", "map": "ClinicalDocument/legalAuthenticator" } ] }, { "id": "DocumentReference.custodian", "path": "DocumentReference.custodian", "short": "Tổ chức lưu trữ và quản lý tài liệu", "definition": "Tổ chức chịu trách nhiệm duy trì và lưu trữ tài liệu. Thường là cơ sở y tế nơi tạo ra và quản lý tài liệu.", "comment": "Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.", "min": 0, "max": "1", "base": { "path": "DocumentReference.custodian", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.custodian" }, { "identity": "rim", "map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]" } ] }, { "id": "DocumentReference.relatesTo", "path": "DocumentReference.relatesTo", "short": "Mối quan hệ với tài liệu khác", "definition": "Mối quan hệ của tài liệu này với các tài liệu khác. Ví dụ: tài liệu thay thế, tài liệu bổ sung, tài liệu chuyển đổi từ.", "comment": "This element is labeled as a modifier because documents that append to other documents are incomplete on their own.", "min": 0, "max": "*", "base": { "path": "DocumentReference.relatesTo", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "fhircomposition", "map": "Composition.relatesTo" }, { "identity": "rim", "map": ".outboundRelationship" }, { "identity": "xds", "map": "DocumentEntry Associations" } ] }, { "id": "DocumentReference.relatesTo.id", "path": "DocumentReference.relatesTo.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "http://hl7.org/fhirpath/System.String", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ] } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.relatesTo.extension", "path": "DocumentReference.relatesTo.extension", "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.relatesTo.modifierExtension", "path": "DocumentReference.relatesTo.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.relatesTo.code", "path": "DocumentReference.relatesTo.code", "short": "replaces | transforms | signs | appends", "definition": "The type of relationship that this document has with anther document.", "comment": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.", "min": 1, "max": "1", "base": { "path": "DocumentReference.relatesTo.code", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentRelationshipType" } ], "strength": "required", "description": "The type of relationship between documents.", "valueSet": "http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1" }, "mapping": [ { "identity": "fhircomposition", "map": "Composition.relatesTo.code" }, { "identity": "rim", "map": ".outboundRelationship.typeCode" }, { "identity": "xds", "map": "DocumentEntry Associations type" } ] }, { "id": "DocumentReference.relatesTo.target", "path": "DocumentReference.relatesTo.target", "short": "Target of the relationship", "definition": "The target document of this relationship.", "min": 1, "max": "1", "base": { "path": "DocumentReference.relatesTo.target", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "fhircomposition", "map": "Composition.relatesTo.target" }, { "identity": "rim", "map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id" }, { "identity": "xds", "map": "DocumentEntry Associations reference" } ] }, { "id": "DocumentReference.description", "path": "DocumentReference.description", "short": "Mô tả về nội dung của tài liệu", "definition": "Mô tả tóm tắt về nội dung chính của tài liệu. Giúp người đọc hiểu nhanh về tài liệu mà không cần mở nội dung chi tiết.", "comment": "What the document is about, a terse summary of the document.", "requirements": "Helps humans to assess whether the document is of interest.", "min": 0, "max": "1", "base": { "path": "DocumentReference.description", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "v2", "map": "TXA-25" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text" }, { "identity": "xds", "map": "DocumentEntry.comments" } ] }, { "id": "DocumentReference.securityLabel", "path": "DocumentReference.securityLabel", "short": "Document security-tags", "definition": "A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the \"reference\" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.", "comment": "The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. \n\nIn the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.", "requirements": "Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.", "min": 0, "max": "*", "base": { "path": "DocumentReference.securityLabel", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "SecurityLabels" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "extensible", "description": "Security Labels from the Healthcare Privacy and Security Classification System.", "valueSet": "http://hl7.org/fhir/ValueSet/security-labels" }, "mapping": [ { "identity": "fhircomposition", "map": "Composition.confidentiality, Composition.meta.security" }, { "identity": "v2", "map": "TXA-18" }, { "identity": "rim", "map": ".confidentialityCode" }, { "identity": "xds", "map": "DocumentEntry.confidentialityCode" }, { "identity": "cda", "map": "ClinicalDocument/confidentialityCode/@code" } ] }, { "id": "DocumentReference.content", "path": "DocumentReference.content", "short": "Nội dung của tài liệu", "definition": "Nội dung thực tế của tài liệu cùng với metadata về định dạng, mã hóa và vị trí lưu trữ.", "min": 1, "max": "*", "base": { "path": "DocumentReference.content", "min": 1, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "fhircomposition", "map": "Bundle(Composition+*)" }, { "identity": "rim", "map": "document.text" } ] }, { "id": "DocumentReference.content.id", "path": "DocumentReference.content.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "http://hl7.org/fhirpath/System.String", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ] } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.extension", "path": "DocumentReference.content.extension", "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.modifierExtension", "path": "DocumentReference.content.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.content.attachment", "path": "DocumentReference.content.attachment", "short": "Tệp tin hoặc URL của tài liệu", "definition": "Tệp tin tài liệu thực tế hoặc URL để truy cập tài liệu. Có thể chứa dữ liệu nhị phân được mã hóa base64 hoặc một URL tham chiếu đến vị trí lưu trữ tài liệu.", "comment": "Nếu có nhiều `DocumentReference.content`, tất cả **PHẢI** đại diện cho cùng một tài liệu ở các định dạng khác nhau (ví dụ: PDF, CDA, XML). Không được chứa các phiên bản khác nhau của cùng tài liệu. Nếu cần quản lý phiên bản, hãy tạo nhiều DocumentReference và liên kết qua `DocumentReference.relatesTo`. Ví dụ: một tài liệu có thể được lưu ở cả định dạng PDF và CDA, nhưng không được lưu hai phiên bản khác nhau của cùng một tài liệu PDF.", "min": 1, "max": "1", "base": { "path": "DocumentReference.content.attachment", "min": 1, "max": "1" }, "type": [ { "code": "Attachment" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "vn-core-1", "human": "DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.", "source": "http://fhir.ironx.io.vn/StructureDefinition/vn-core-documentreference", "severity": "error", "expression": "url.exists() or data.exists()", "xpath": "f:url or f:content" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "fhircomposition", "map": "Composition.language, \nComposition.title, \nComposition.date" }, { "identity": "v2", "map": "TXA-3 for mime type" }, { "identity": "rim", "map": "document.text" }, { "identity": "xds", "map": "DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime" }, { "identity": "cda", "map": "ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date" } ] }, { "id": "DocumentReference.content.attachment.id", "path": "DocumentReference.content.attachment.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "http://hl7.org/fhirpath/System.String", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ] } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.attachment.extension", "path": "DocumentReference.content.attachment.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "short": "Mime type of the content, with charset etc.", "definition": "Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.", "requirements": "Processors of the data need to be able to know how to interpret the data.", "min": 0, "max": "1", "base": { "path": "Attachment.contentType", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "example": [ { "label": "General", "valueCode": "text/plain; charset=UTF-8, image/png" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "MimeType" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "required", "description": "The mime type of an attachment. Any valid mime type is allowed.", "valueSet": "http://hl7.org/fhir/ValueSet/mimetypes|4.0.1" }, "mapping": [ { "identity": "v2", "map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used" }, { "identity": "rim", "map": "./mediaType, ./charset" } ] }, { "id": "DocumentReference.content.attachment.language", "path": "DocumentReference.content.attachment.language", "short": "Human language of the content (BCP-47)", "definition": "The human language of the content. The value can be any valid value according to BCP 47.", "requirements": "Users need to be able to choose between the languages in a set of attachments.", "min": 0, "max": "1", "base": { "path": "Attachment.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "example": [ { "label": "General", "valueCode": "en-AU" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "preferred", "description": "A human language.", "valueSet": "http://hl7.org/fhir/ValueSet/languages" }, "mapping": [ { "identity": "rim", "map": "./language" } ] }, { "id": "DocumentReference.content.attachment.data", "path": "DocumentReference.content.attachment.data", "short": "Data inline, base64ed", "definition": "The actual data of the attachment - a sequence of bytes, base64 encoded.", "comment": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.", "requirements": "The data needs to able to be transmitted inline.", "min": 0, "max": "1", "base": { "path": "Attachment.data", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "v2", "map": "ED.5" }, { "identity": "rim", "map": "./data" } ] }, { "id": "DocumentReference.content.attachment.url", "path": "DocumentReference.content.attachment.url", "short": "Uri where the data can be found", "definition": "A location where the data can be accessed.", "comment": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.", "requirements": "The data needs to be transmitted by reference.", "min": 0, "max": "1", "base": { "path": "Attachment.url", "min": 0, "max": "1" }, "type": [ { "code": "url" } ], "example": [ { "label": "General", "valueUrl": "http://www.acme.com/logo-small.png" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "v2", "map": "RP.1+RP.2 - if they refer to a URL (see v2.6)" }, { "identity": "rim", "map": "./reference/literal" } ] }, { "id": "DocumentReference.content.attachment.size", "path": "DocumentReference.content.attachment.size", "short": "Number of bytes of content (if url provided)", "definition": "The number of bytes of data that make up this attachment (before base64 encoding, if that is done).", "comment": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.", "requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.", "min": 0, "max": "1", "base": { "path": "Attachment.size", "min": 0, "max": "1" }, "type": [ { "code": "unsignedInt" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A (needs data type R3 proposal)" } ] }, { "id": "DocumentReference.content.attachment.hash", "path": "DocumentReference.content.attachment.hash", "short": "Hash of the data (sha-1, base64ed)", "definition": "The calculated hash of the data using SHA-1. Represented using base64.", "comment": "The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.", "requirements": "Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).", "min": 0, "max": "1", "base": { "path": "Attachment.hash", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]" } ] }, { "id": "DocumentReference.content.attachment.title", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.content.attachment.title", "short": "Label to display in place of the data", "definition": "A label or set of text to display in place of the data.", "requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.", "min": 0, "max": "1", "base": { "path": "Attachment.title", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "Official Corporate Logo" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "./title/data" } ] }, { "id": "DocumentReference.content.attachment.creation", "path": "DocumentReference.content.attachment.creation", "short": "Date attachment was first created", "definition": "The date that the attachment was first created.", "requirements": "This is often tracked as an integrity issue for use of the attachment.", "min": 0, "max": "1", "base": { "path": "Attachment.creation", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A (needs data type R3 proposal)" } ] }, { "id": "DocumentReference.content.format", "path": "DocumentReference.content.format", "short": "Format/content rules for the document", "definition": "An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.", "comment": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.", "min": 0, "max": "1", "base": { "path": "DocumentReference.content.format", "min": 0, "max": "1" }, "type": [ { "code": "Coding" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentFormat" } ], "strength": "preferred", "description": "Document Format Codes.", "valueSet": "http://hl7.org/fhir/ValueSet/formatcodes" }, "mapping": [ { "identity": "fhircomposition", "map": "Composition.meta.profile" }, { "identity": "rim", "map": "document.text" }, { "identity": "xds", "map": "DocumentEntry.formatCode" }, { "identity": "cda", "map": "derived from the IHE Profile or Implementation Guide templateID" } ] }, { "id": "DocumentReference.context", "path": "DocumentReference.context", "short": "Bối cảnh của tài liệu", "definition": "Bối cảnh lâm sàng của tài liệu bao gồm lần khám/điều trị liên quan, thời gian và các thông tin khác giúp hiểu rõ hoàn cảnh tạo ra tài liệu.", "comment": "These values are primarily added to help with searching for interesting/relevant documents.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "rim", "map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']" } ] }, { "id": "DocumentReference.context.id", "path": "DocumentReference.context.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "http://hl7.org/fhirpath/System.String", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ] } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.extension", "path": "DocumentReference.context.extension", "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.modifierExtension", "path": "DocumentReference.context.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.encounter", "path": "DocumentReference.context.encounter", "short": "Lần khám/điều trị liên quan", "definition": "Lần khám bệnh hoặc điều trị mà tài liệu này được tạo ra trong đó. Ví dụ: lần khám ngoại trú, đợt điều trị nội trú, hoặc thủ thuật cụ thể.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.encounter", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-encounter" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "mapping": [ { "identity": "workflow", "map": "Event.context" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "fhircomposition", "map": "Composition.encounter" }, { "identity": "rim", "map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])" } ] }, { "id": "DocumentReference.context.event", "path": "DocumentReference.context.event", "short": "Main clinical acts documented", "definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act.", "comment": "An event can further specialize the act inherent in the type, such as where it is simply \"Procedure Report\" and the procedure was a \"colonoscopy\". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.", "min": 0, "max": "*", "base": { "path": "DocumentReference.context.event", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentEventType" } ], "strength": "example", "description": "This list of codes represents the main clinical acts being documented.", "valueSet": "http://terminology.hl7.org/ValueSet/v3-ActCode" }, "mapping": [ { "identity": "fhircomposition", "map": "Composition.event.code" }, { "identity": "rim", "map": ".code" }, { "identity": "xds", "map": "DocumentEntry.eventCodeList" } ] }, { "id": "DocumentReference.context.period", "path": "DocumentReference.context.period", "short": "Thời gian liên quan", "definition": "Khoảng thời gian mà tài liệu đề cập đến. Ví dụ: thời gian nằm viện đối với giấy ra viện, hoặc thời gian diễn ra thủ thuật đối với biên bản phẫu thuật.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": true, "mapping": [ { "identity": "fhircomposition", "map": "Composition.event.period" }, { "identity": "rim", "map": ".effectiveTime" }, { "identity": "xds", "map": "DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime" }, { "identity": "cda", "map": "ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/low/\n@value --> ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/high/\n@value" } ] }, { "id": "DocumentReference.context.facilityType", "path": "DocumentReference.context.facilityType", "short": "Loại cơ sở y tế", "definition": "Loại cơ sở y tế nơi tạo ra tài liệu. Ví dụ: bệnh viện, phòng khám, trạm y tế.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.facilityType", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80FacilityType" } ], "strength": "example", "description": "XDS Facility Type.", "valueSet": "http://hl7.org/fhir/ValueSet/c80-facilitycodes" }, "mapping": [ { "identity": "fhircomposition", "map": "usually from a mapping to a local ValueSet" }, { "identity": "rim", "map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code" }, { "identity": "xds", "map": "DocumentEntry.healthcareFacilityTypeCode" }, { "identity": "cda", "map": "usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code" } ] }, { "id": "DocumentReference.context.practiceSetting", "path": "DocumentReference.context.practiceSetting", "short": "Additional details about where the content was created (e.g. clinical specialty)", "definition": "This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.", "comment": "This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.", "requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.practiceSetting", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80PracticeSetting" } ], "strength": "example", "description": "Additional details about where the content was created (e.g. clinical specialty).", "valueSet": "http://hl7.org/fhir/ValueSet/c80-practice-codes" }, "mapping": [ { "identity": "fhircomposition", "map": "usually from a mapping to a local ValueSet" }, { "identity": "rim", "map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code" }, { "identity": "xds", "map": "DocumentEntry.practiceSettingCode" }, { "identity": "cda", "map": "usually from a mapping to a local ValueSet" } ] }, { "id": "DocumentReference.context.sourcePatientInfo", "path": "DocumentReference.context.sourcePatientInfo", "short": "Patient demographics from source", "definition": "The Patient Information as known when the document was published. May be a reference to a version specific, or contained.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.sourcePatientInfo", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "fhircomposition", "map": "Composition.subject" }, { "identity": "rim", "map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]" }, { "identity": "xds", "map": "DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId" }, { "identity": "cda", "map": "ClinicalDocument/recordTarget/" } ] }, { "id": "DocumentReference.context.related", "path": "DocumentReference.context.related", "short": "Related identifiers or resources", "definition": "Related identifiers or resources associated with the DocumentReference.", "comment": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.", "min": 0, "max": "*", "base": { "path": "DocumentReference.context.related", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": false, "isSummary": false, "mapping": [ { "identity": "fhircomposition", "map": "Composition.event.detail" }, { "identity": "rim", "map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]" }, { "identity": "xds", "map": "DocumentEntry.referenceIdList" }, { "identity": "cda", "map": "ClinicalDocument/relatedDocument" } ] } ] }, "differential": { "element": [ { "id": "DocumentReference", "path": "DocumentReference", "short": "Tham chiếu tới tài liệu điện tử", "definition": "Tham chiếu và siêu dữ liệu về một tài liệu của bất kỳ loại nào cho mục đích lâm sàng, hành chính hoặc bằng chứng chất lượng. Đây có thể là tài liệu đã được số hóa hoặc tài liệu gốc điện tử.", "mustSupport": false }, { "id": "DocumentReference.identifier", "path": "DocumentReference.identifier", "short": "Mã định danh tài liệu", "definition": "Mã định danh duy nhất của tài liệu trong hệ thống. Có thể là mã số hồ sơ bệnh án, số phiếu xét nghiệm, số đơn thuốc, v.v.", "comment": "Nên sử dụng hệ thống định danh thống nhất trong tổ chức. Ví dụ: BA{năm}{số_thứ_tự} cho bệnh án, XN{năm}{số_thứ_tự} cho phiếu xét nghiệm.", "mustSupport": true }, { "id": "DocumentReference.status", "path": "DocumentReference.status", "short": "Trạng thái của tài liệu", "definition": "Trạng thái hiện tại của tài liệu tham chiếu. Có thể là: current (hiện hành), superseded (đã được thay thế), entered-in-error (nhập sai).", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://hl7.org/fhir/ValueSet/document-reference-status" } }, { "id": "DocumentReference.type", "path": "DocumentReference.type", "short": "Loại tài liệu", "definition": "Loại cụ thể của tài liệu (ví dụ: bệnh án, đơn thuốc, phiếu xét nghiệm, v.v.)", "min": 1, "mustSupport": true }, { "id": "DocumentReference.category", "path": "DocumentReference.category", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "min": 1, "mustSupport": true }, { "id": "DocumentReference.category:vncore", "path": "DocumentReference.category", "sliceName": "vncore", "short": "Phân loại tài liệu (VN Core)", "min": 0, "max": "*", "mustSupport": true }, { "id": "DocumentReference.subject", "path": "DocumentReference.subject", "short": "Đối tượng được đề cập trong tài liệu", "definition": "Đối tượng chính mà tài liệu đề cập đến. Thông thường là bệnh nhân, nhưng cũng có thể là nhân viên y tế (trong trường hợp tài liệu về nhân sự), thiết bị (trong trường hợp tài liệu kỹ thuật), hoặc nhóm bệnh nhân (trong trường hợp báo cáo nhóm).", "comment": "Trường này bắt buộc phải có và thường tham chiếu đến Patient. Trong một số trường hợp đặc biệt có thể tham chiếu đến các đối tượng khác như Practitioner, Device hoặc Group tùy theo nội dung tài liệu.", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-patient", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-group", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-device" ], "_targetProfile": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": true } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] } ] } ], "mustSupport": true }, { "id": "DocumentReference.date", "path": "DocumentReference.date", "short": "Thời điểm tạo DocumentReference", "definition": "Thời điểm tạo bản ghi DocumentReference này trên hệ thống, không phải thời điểm tạo tài liệu gốc. Thời điểm tạo tài liệu gốc được lưu trong DocumentReference.content.attachment.creation. Trường này có thể dùng để theo dõi thời điểm số hóa tài liệu giấy hoặc thời điểm nhập tài liệu vào hệ thống.", "comment": "Đây là thời điểm metadata về tài liệu được tạo ra, khác với thời điểm tạo ra nội dung tài liệu. Ví dụ: một bệnh án được viết ngày 01/01/2025 (DocumentReference.content.attachment.creation) nhưng được scan và tạo DocumentReference vào ngày 15/01/2025 (DocumentReference.date).", "mustSupport": true }, { "id": "DocumentReference.author", "path": "DocumentReference.author", "short": "Người/tổ chức tạo ra tài liệu", "definition": "Người hoặc tổ chức chịu trách nhiệm chính về nội dung của tài liệu. Ví dụ: bác sĩ viết bệnh án, kỹ thuật viên thực hiện xét nghiệm, hoặc bệnh nhân trong trường hợp tự ghi chép.", "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-patient", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitionerrole", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-relatedperson", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-device" ], "_targetProfile": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": true } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support", "valueBoolean": false } ] } ] } ], "mustSupport": true }, { "id": "DocumentReference.authenticator", "path": "DocumentReference.authenticator", "short": "Người xác thực tài liệu", "definition": "Người có thẩm quyền xác thực tính chính xác và hợp pháp của tài liệu. Ví dụ: Trưởng khoa ký bệnh án, Giám đốc bệnh viện ký giấy ra viện.", "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitioner", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-practitionerrole", "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization" ] } ], "mustSupport": true }, { "id": "DocumentReference.custodian", "path": "DocumentReference.custodian", "short": "Tổ chức lưu trữ và quản lý tài liệu", "definition": "Tổ chức chịu trách nhiệm duy trì và lưu trữ tài liệu. Thường là cơ sở y tế nơi tạo ra và quản lý tài liệu.", "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-organization" ] } ], "mustSupport": true }, { "id": "DocumentReference.relatesTo", "path": "DocumentReference.relatesTo", "short": "Mối quan hệ với tài liệu khác", "definition": "Mối quan hệ của tài liệu này với các tài liệu khác. Ví dụ: tài liệu thay thế, tài liệu bổ sung, tài liệu chuyển đổi từ.", "mustSupport": true }, { "id": "DocumentReference.description", "path": "DocumentReference.description", "short": "Mô tả về nội dung của tài liệu", "definition": "Mô tả tóm tắt về nội dung chính của tài liệu. Giúp người đọc hiểu nhanh về tài liệu mà không cần mở nội dung chi tiết.", "mustSupport": true }, { "id": "DocumentReference.content", "path": "DocumentReference.content", "short": "Nội dung của tài liệu", "definition": "Nội dung thực tế của tài liệu cùng với metadata về định dạng, mã hóa và vị trí lưu trữ.", "mustSupport": true }, { "id": "DocumentReference.content.attachment", "path": "DocumentReference.content.attachment", "short": "Tệp tin hoặc URL của tài liệu", "definition": "Tệp tin tài liệu thực tế hoặc URL để truy cập tài liệu. Có thể chứa dữ liệu nhị phân được mã hóa base64 hoặc một URL tham chiếu đến vị trí lưu trữ tài liệu.", "comment": "Nếu có nhiều `DocumentReference.content`, tất cả **PHẢI** đại diện cho cùng một tài liệu ở các định dạng khác nhau (ví dụ: PDF, CDA, XML). Không được chứa các phiên bản khác nhau của cùng tài liệu. Nếu cần quản lý phiên bản, hãy tạo nhiều DocumentReference và liên kết qua `DocumentReference.relatesTo`. Ví dụ: một tài liệu có thể được lưu ở cả định dạng PDF và CDA, nhưng không được lưu hai phiên bản khác nhau của cùng một tài liệu PDF.", "constraint": [ { "key": "vn-core-1", "human": "DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.", "source": "http://fhir.ironx.io.vn/StructureDefinition/vn-core-documentreference", "severity": "error", "expression": "url.exists() or data.exists()", "xpath": "f:url or f:content" } ], "mustSupport": true }, { "id": "DocumentReference.content.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "mustSupport": true }, { "id": "DocumentReference.content.attachment.data", "path": "DocumentReference.content.attachment.data", "mustSupport": true }, { "id": "DocumentReference.content.attachment.url", "path": "DocumentReference.content.attachment.url", "mustSupport": true }, { "id": "DocumentReference.content.format", "path": "DocumentReference.content.format", "mustSupport": true }, { "id": "DocumentReference.context", "path": "DocumentReference.context", "short": "Bối cảnh của tài liệu", "definition": "Bối cảnh lâm sàng của tài liệu bao gồm lần khám/điều trị liên quan, thời gian và các thông tin khác giúp hiểu rõ hoàn cảnh tạo ra tài liệu.", "mustSupport": true }, { "id": "DocumentReference.context.encounter", "path": "DocumentReference.context.encounter", "short": "Lần khám/điều trị liên quan", "definition": "Lần khám bệnh hoặc điều trị mà tài liệu này được tạo ra trong đó. Ví dụ: lần khám ngoại trú, đợt điều trị nội trú, hoặc thủ thuật cụ thể.", "max": "1", "type": [ { "code": "Reference", "targetProfile": [ "http://fhir.ironx.io.vn/StructureDefinition/vn-core-encounter" ] } ], "mustSupport": true }, { "id": "DocumentReference.context.period", "path": "DocumentReference.context.period", "short": "Thời gian liên quan", "definition": "Khoảng thời gian mà tài liệu đề cập đến. Ví dụ: thời gian nằm viện đối với giấy ra viện, hoặc thời gian diễn ra thủ thuật đối với biên bản phẫu thuật.", "mustSupport": true }, { "id": "DocumentReference.context.facilityType", "path": "DocumentReference.context.facilityType", "short": "Loại cơ sở y tế", "definition": "Loại cơ sở y tế nơi tạo ra tài liệu. Ví dụ: bệnh viện, phòng khám, trạm y tế.", "mustSupport": true } ] } }