1. 診斷工作流程
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——服務請求
{
"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. 標本－病人樣本
{
"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——報告結果
診斷報告 診斷結果的綜合－包括血液檢查、X光影像、超音波、心電圖等。
診斷報告結構
| 元素 | 基數 | 描述 |
|---|---|---|
| 狀態。狀態 | 1..1 | 註冊|部分 |初步|修改|決賽|改變|更正|附加|取消 |輸入錯誤 |
| 類別。類別 | 0..* | 實驗室|雷達 |帕特 | ...（報告類型） |
| 程式碼 | 1..1 | 測試/報告代碼 (LOINC) |
| 主題。主題 | 1..1 | 參考（患者） |
| 相遇。遭遇 | 0..1 | 參考（遭遇） |
| 有效[x] | 0..1 | 實施時間/持續時間 |
| 發出。發出 | 0..1 | 回傳結果的時間 |
| 表演者 | 0..* | 實施人/單位 |
| 標本。標本 | 0..* | 參考（樣本） |
| 結果。結果 | 0..* | 參考（觀察）－結果指數 |
| 結論 | 0..1 | 評論/結論 |
| 媒體。媒體 | 0..* | 附圖 |
範例：CBC 測試結果
{
"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. 程序 — 程序/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. 過敏不耐症－過敏
{
"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"
}
]
}
七、總結
服務請求 → 樣本 → 觀察 → 診斷報告 — 完整的診斷工作流程
診斷報告 — 總結結果，收集許多觀察、結論、圖像
程式 — 程序/手術，代碼為 SNOMED/CPT、執行者、結果
過敏不耐症 — 藥物/食物/環境過敏、反應、危急程度