1. 診断ワークフロー
Bác sĩ yêu cầu Lấy mẫu Phòng xét nghiệm Trả kết quả
│ │ │ │
▼ ▼ ▼ ▼
ServiceRequest ──▶ Specimen ──▶ Observation(s) ──▶ DiagnosticReport
(order) (bệnh phẩm) (từng chỉ số) (báo cáo tổng hợp)
2. ServiceRequest — サービスリクエスト
{
"resourceType": "ServiceRequest",
"id": "sr-cbc-001",
"status": "completed",
"intent": "order",
"category": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "108252007",
"display": "Laboratory procedure"
}
]
}
],
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "58410-2",
"display": "Complete blood count (CBC) panel - Blood by Automated count"
}
],
"text": "Công thức máu toàn phần"
},
"subject": {
"reference": "Patient/patient-001"
},
"encounter": {
"reference": "Encounter/encounter-outpatient-001"
},
"authoredOn": "2025-01-15T08:20:00+07:00",
"requester": {
"reference": "Practitioner/practitioner-001",
"display": "BS. Trần Thị B"
},
"specimen": [
{
"reference": "Specimen/specimen-blood-001"
}
]
}
3. 検体 - 患者サンプル
{
"resourceType": "Specimen",
"id": "specimen-blood-001",
"type": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "119297000",
"display": "Blood specimen"
}
],
"text": "Mẫu máu tĩnh mạch"
},
"subject": {
"reference": "Patient/patient-001"
},
"receivedTime": "2025-01-15T08:30:00+07:00",
"collection": {
"collectedDateTime": "2025-01-15T08:25:00+07:00",
"quantity": {
"value": 5,
"unit": "mL"
},
"bodySite": {
"concept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "49852007",
"display": "Structure of median cubital vein"
}
],
"text": "Tĩnh mạch giữa khuỷu tay"
}
}
},
"container": [
{
"device": {
"concept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "706050005",
"display": "EDTA blood collection tube"
}
],
"text": "Ống EDTA (nắp tím)"
}
}
}
]
}
4. DiagnosticReport — 結果をレポートする
診断レポート 血液検査、X線画像、超音波、ECGなどの診断結果の総合。
DiagnosticReport の構造
| 要素 | カーディナリティ | 説明 |
|---|---|---|
| ステータス。ステータス | 1..1 | 登録済み |部分的 |予備 |変更されました |最終 |変更された |修正しました |追加 |キャンセルされました |誤って入力されました |
| カテゴリ。カテゴリ | 0..* | ラボ |ラッド |パット | ... (レポートタイプ) |
| コード | 1..1 | テスト/レポートコード (LOINC) |
| 主題。件名 | 1..1 | 参考人（患者） |
| 出会い。出会い | 0..1 | リファレンス(出会い) |
| 有効[x] | 0..1 | 実施時期・期間 |
| 発行されました。発行された | 0..1 | 結果を返すまでの時間 |
| 出演者 | 0..* | 実施者・単位 |
| 標本。標本 | 0..* | リファレンス(試料) |
| 結果。結果 | 0..* | 参照(観察) — 結果インデックス |
| 結論 | 0..1 | コメント/結論 |
| メディア。メディア | 0..* | 添付画像 |
例: CBC テスト結果
{
"resourceType": "DiagnosticReport",
"id": "dr-cbc-001",
"status": "final",
"category": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0074",
"code": "LAB",
"display": "Laboratory"
}
]
}
],
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "58410-2",
"display": "CBC panel - Blood by Automated count"
}
],
"text": "Công thức máu toàn phần"
},
"subject": {
"reference": "Patient/patient-001"
},
"encounter": {
"reference": "Encounter/encounter-outpatient-001"
},
"effectiveDateTime": "2025-01-15T09:00:00+07:00",
"issued": "2025-01-15T10:30:00+07:00",
"performer": [
{
"reference": "Organization/org-lab-001",
"display": "Khoa Xét nghiệm - BVĐK TW"
}
],
"specimen": [
{
"reference": "Specimen/specimen-blood-001"
}
],
"result": [
{
"reference": "Observation/obs-wbc-001",
"display": "WBC: 8.5 x10^9/L"
},
{
"reference": "Observation/obs-rbc-001",
"display": "RBC: 4.8 x10^12/L"
},
{
"reference": "Observation/obs-hgb-001",
"display": "Hemoglobin: 14.2 g/dL"
},
{
"reference": "Observation/obs-plt-001",
"display": "Platelets: 250 x10^9/L"
}
],
"conclusion": "Công thức máu trong giới hạn bình thường. Không phát hiện bất thường."
}
5. 手順 — 手順/手術
{
"resourceType": "Procedure",
"id": "proc-appendectomy-001",
"status": "completed",
"category": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "387713003",
"display": "Surgical procedure"
}
]
}
],
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "80146002",
"display": "Appendectomy"
},
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "44970",
"display": "Laparoscopic appendectomy"
}
],
"text": "Cắt ruột thừa nội soi"
},
"subject": {
"reference": "Patient/patient-004"
},
"encounter": {
"reference": "Encounter/encounter-inpatient-002"
},
"occurrencePeriod": {
"start": "2025-01-14T14:00:00+07:00",
"end": "2025-01-14T15:30:00+07:00"
},
"performer": [
{
"function": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "304292004",
"display": "Surgeon"
}
]
},
"actor": {
"reference": "Practitioner/practitioner-surgeon-001",
"display": "BS. Phạm Quốc D"
}
}
],
"reason": [
{
"reference": {
"reference": "Condition/cond-appendicitis-001",
"display": "Viêm ruột thừa cấp"
}
}
],
"bodySite": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "66754008",
"display": "Appendix structure"
}
]
}
],
"outcome": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "385669000",
"display": "Successful"
}
],
"text": "Phẫu thuật thành công, không biến chứng"
}
}
6. アレルギー不耐症 — アレルギー
{
"resourceType": "AllergyIntolerance",
"id": "allergy-penicillin-001",
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code": "active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code": "confirmed"
}
]
},
"type": "allergy",
"category": ["medication"],
"criticality": "high",
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "764146007",
"display": "Penicillin"
}
],
"text": "Dị ứng Penicillin"
},
"patient": {
"reference": "Patient/patient-001"
},
"onsetDateTime": "2020-05-10",
"recordedDate": "2020-05-12",
"recorder": {
"reference": "Practitioner/practitioner-001"
},
"reaction": [
{
"substance": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "764146007",
"display": "Penicillin"
}
]
},
"manifestation": [
{
"concept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "271807003",
"display": "Skin rash"
}
],
"text": "Phát ban da"
}
},
{
"concept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "267036007",
"display": "Dyspnea"
}
],
"text": "Khó thở"
}
}
],
"severity": "severe"
}
]
}
7. まとめ
ServiceRequest → 検体 → 観察 → DiagnosticReport — 完全な診断ワークフロー
診断レポート — 結果を要約し、多くの観察、結論、画像を収集します
手順 — コードSNOMED/CPTを含む手順/手術、実行者、結果
アレルギー不耐症 — 薬物/食品/環境アレルギー、反応、重大性