Narrativa gerada: StructureDefinition br-core-capacidadefuncional Nome Bandeiras Card. Tipo Descrição e condicionalismos Condition 0..* BRCoreCondition Detailed information about conditions, problems or diagnoses #xD; clinicalStatus 1..1 CodeableConcept O status clínico da condição ou do diagnóstico #xD; coding 0..* Coding Code defined by a terminology system #xD; system 1..1 uri Identificador do sistema de terminologia #xD; version 0..1 string Versão do sistema de terminologia, se relevante #xD; code 1..1 code Símbolo na sintaxe definida pelo sistema #xD; display 0..1 string Representação definida pelo sistema #xD; userSelected 0..1 boolean Se este código foi escolhido diretamente pelo usuário #xD; text 0..1 string Representação em texto livre do conceito #xD; verificationStatus 0..1 CodeableConcept O status de verificação para apoiar ou recusar o status clínico da condição ou do diagnóstico #xD; category 0..1 CodeableConcept Categoria da condição Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRCategoriaDiagnostico (required) #xD; code 1..1 CodeableConcept Identifica a suspeita diagnóstica com relação à condição de saúde avaliada Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRTerminologiaSuspeitaDiagnostica (required) #xD; subject 1..1 Reference(BRCorePatient) Indivíduo com a Condição de Saúde avaliada #xD; identifier 1..1 Identifier Referência lógica, quando a referência literal não é conhecida #xD; id 0..1 string Identificador único para referência cruzada #xD; extension 0..* Extension Extensões adicionais definidas pela implementação #xD; type 0..1 CodeableConcept Descrição do identificador #xD; system 1..1 uri O namespace do valor do identificador #xD; value 1..1 string Valor único do identificador #xD; period 0..1 Period Período de tempo no qual este identicador é/ou foi válido para utilização #xD; assigner 0..1 Reference(Organization) Organização que emitiu o documento de identificação (pode ser apenas texto) #xD; recordedDate 0..1 dateTime Data na qual o registro foi registrado pela primeira vez #xD; stage 1..* BackboneElement Estágio/grau da condição, geralmente avaliado formalmente #xD; assessment 0..* Reference(ClinicalImpression | BRCoreDiagnosticReport | BRCoreObservation) Referência aos dados de diagnóstico de laboratório clínico relacionados à suspeita diagnóstica #xD; evidence #xD; code 0..* CodeableConcept Manifestação/sintoma #xD; detail 0..* Reference(Resource) Referência à informações de apoio #xD; Documentação para este formato
Este perfil herda do recurso [br-core-condition](StructureDefinition-br-core-condition.html)
Detailed information about conditions, problems or diagnoses
A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.
Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
exists(f:clinicalStatus) or exists(f:verificationStatus/f:coding/f:code/@value='entered-in-error') or not(exists(category[@value='problem-list-item']))
If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
not(exists(*[starts-with(local-name(.), 'abatement')])) or exists(f:clinicalStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-clinical' and f:code/@value=('resolved', 'remission', 'inactive')])
Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
not(exists(f:verificationStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-ver-status' and f:code/@value='entered-in-error'])) or not(exists(f:clinicalStatus))
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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
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()
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='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
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.
A resource should have narrative for robust management
< 243796009 |Situation with explicit context| : 246090004 |Associated finding| = ( ( < 404684003 |Clinical finding| MINUS ( << 420134006 |Propensity to adverse reactions| OR << 473010000 |Hypersensitivity condition| OR << 79899007 |Drug interaction| OR << 69449002 |Drug action| OR << 441742003 |Evaluation finding| OR << 307824009 |Administrative status| OR << 385356007 |Tumor stage finding|)) OR < 272379006 |Event|)
Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Um conjunto de regras sob as quais este conteúdo foi criado
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.
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
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).
Resumo do texto do recurso em linguagem natural
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.
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.
Extensões adicionais que não fazem parte do modelo base
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Identificadores externos para este recurso
This is a business identifier, not a resource identifier (see [discussion](http://hl7.org/fhir/R4/resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.
O status clínico da condição ou do diagnóstico
The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.
The clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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.
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.
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Identificador do sistema de terminologia
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Versão do sistema de terminologia, se relevante
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Símbolo na sintaxe definida pelo sistema
Need to refer to a particular code in the system.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Se este código foi escolhido diretamente pelo usuário
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Representação em texto livre do conceito
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
O status de verificação para apoiar ou recusar o status clínico da condição ou do diagnóstico
verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.
The verification status to support or decline the clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value
The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message
Coding of the severity with a terminology is preferred, where possible.
A subjective assessment of the severity of the condition as evaluated by the clinician.
Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value
Identifica a suspeita diagnóstica com relação à condição de saúde avaliada
0..1 to account for primarily narrative only resources.
code 246090004 |Associated finding| (< 404684003 |Clinical finding| MINUS << 420134006 |Propensity to adverse reactions| MINUS << 473010000 |Hypersensitivity condition| MINUS << 79899007 |Drug interaction| MINUS << 69449002 |Drug action| MINUS << 441742003 |Evaluation finding| MINUS << 307824009 |Administrative status| MINUS << 385356007 |Tumor stage finding|) OR < 413350009 |Finding with explicit context| OR < 272379006 |Event|
Local anatômico da condição, se relevante
Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [bodySite](http://hl7.org/fhir/R4/extension-bodysite.html). May be a summary code, or a reference to a very precise definition of the location, or both.
< 442083009 |Anatomical or acquired body structure|
Indivíduo com a Condição de Saúde avaliada
Group is typically used for veterinary or public health use cases.
Identificador único para referência cruzada
Extensões adicionais que não fazem parte do modelo de dados básico
Referência literal. URL relativa, interna ou externa
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Tipo de recurso ao qual a referência é feita
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Referência lógica, quando a referência literal não é conhecida
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Extensões adicionais definidas pela implementação
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Identifier.system is always case sensitive.
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Período de tempo no qual este identicador é/ou foi válido para utilização
Role.effectiveTime or implied by context
Organização que emitiu o documento de identificação (pode ser apenas texto)
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Referência ao atendimento no qual a condição foi diagnosticada
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Data ou idade estimada ou real do começo dos sintomas
Age is generally used when the patient reports an age at which the Condition began to occur.
.effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
Data ou idade estimada ou real em que o diagnóstico foi resolvido ou entrou em remissão
There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
.effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
Data na qual o registro foi registrado pela primeira vez
Estágio/grau da condição, geralmente avaliado formalmente
exists(f:summary) or exists(f:assessment)
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Códigos descrevendo estágios da condição (por exemplo, estágios de câncer)
Codes describing condition stages (e.g. Cancer stages).
Referência aos dados de diagnóstico de laboratório clínico relacionados à suspeita diagnóstica
Códigos que descrevem o tipo do estadiamento (por exemplo, clínico ou patológico)
Codes describing the kind of condition staging (e.g. clinical or pathological).
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]
The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
.outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
Códigos que descrevem a manifestação ou sintomas de uma condição
Codes that describe the manifestation or symptoms of a condition.
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value