Narrativa gerada: StructureDefinition br-core-diagnosticreport Nome Bandeiras Card. Tipo Descrição e condicionalismos DiagnosticReport DiagnosticReport #xD; id 0..1 id Identificador lógico deste artefato #xD; meta 0..1 Meta Metadados sobre o recurso #xD; implicitRules 0..1 uri Um conjunto de regras sob as quais este conteúdo foi criado #xD; language 0..1 code Idioma do recurso #xD; text 0..1 Narrative Resumo do texto do recurso em linguagem natural #xD; contained 0..* Resource Recursos contidos no recurso #xD; extension 0..* Extension Extensões adicionais que não fazem parte do modelo base #xD; modifierExtension 0..* Extension Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas #xD; identifier 0..* Identifier Identificadores externos para este recurso #xD; basedOn 0..* Reference(BRCoreCarePlan | ImmunizationRecommendation | br-core-medicationrequest | NutritionOrder | BRCoreServiceRequest) O que foi solicitado #xD; status 1..1 code O status do relatório de diagnóstico #xD; category 0..* CodeableConcept Categoria do serviço Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRServicoEspecializado (required) #xD; code 1..1 CodeableConcept Nome/Código para este relatório de diagnóstico #xD; subject 0..1 Reference(BRCorePatient) O indivíduo do relatório - geralmente, mas nem sempre, o paciente #xD; encounter 0..1 Reference(br-core-encounter) Evento de assistência médica quando o teste foi solicitado #xD; effective[x] 0..1 dateTime, Period Tempo/período de tempo clinicamente relevante para o relatório #xD; issued 0..1 instant Data e hora em que esta versão foi feita #xD; performer 0..* Reference(BRCorePractitioner | BRCorePractitionerRole | BRCoreOrganization | CareTeam) Serviço de diagnóstico (SADT) responsável #xD; resultsInterpreter 0..* Reference(BRCorePractitioner | BRCorePractitionerRole | BRCoreOrganization | CareTeam) Intérprete de resultado #xD; specimen 0..* Reference(BRCoreSpecimen) Amostras deste relatório #xD; result 0..* Reference(BRCoreObservation) Observations #xD; imagingStudy 0..* Reference(ImagingStudy) Referência as imagens associadas ao relatório de diagnóstico ao relatório de diagnóstico #xD; media 0..* BackboneElement Imagens associadas a este relatório #xD; id 0..1 string Identificador único para referência cruzada #xD; extension 0..* Extension Extensões adicionais que não fazem parte do modelo de dados básico #xD; modifierExtension 0..* Extension Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas #xD; comment 0..1 string Comentário sobre a imagem #xD; link 1..1 Reference(Media) Referência à fonte da imagem #xD; conclusion 0..1 string Conclusão clínica (interpretação) dos resultados #xD; conclusionCode 0..* CodeableConcept Códigos da conclusão clínica dos resultados #xD; presentedForm 0..* Attachment Relatório completo conforme emitido #xD; Documentação para este formato
Este perfil restringe o recurso [DiagnosticReport](https://hl7.org/fhir/R4/diagnosticreport.html) que representa as descobertas e a interpretação de testes diagnósticos realizados em pacientes, grupos de pacientes, dispositivos e locais, e/ou espécimes derivados destes. O relatório inclui contexto clínico, como solicitação e informações do provedor, e alguma mistura de resultados atômicos, imagens, interpretações textuais e codificadas, e representação formatada de relatórios diagnósticos
A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
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
Observation[classCode=OBS, moodCode=EVN]
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
Usually assigned by the Information System of the diagnostic service provider (filler id).
Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
This element is labeled 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
statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
Nome/Código para este relatório de diagnóstico
OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
O indivíduo do relatório - geralmente, mas nem sempre, o paciente
PID-3 (no HL7 v2 mapping for Group or Device)
Evento de assistência médica quando o teste foi solicitado
This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Links the request to the Encounter context.
inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Tempo/período de tempo clinicamente relevante para o relatório
If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Need to know where in the patient history to file/present this report.
Data e hora em que esta versão foi feita
May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
Clinicians need to be able to check the date that the report was released.
Serviço de diagnóstico (SADT) responsável
This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
PRT-8 (where this PRT-4-Participation = "PO")
Might not be the same entity that takes responsibility for the clinical report.
OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Need to be able to report information about the collected specimens on which the report is based.
Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Referência as imagens associadas ao relatório de diagnóstico ao relatório de diagnóstico
ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
Many diagnostic services include images in the report as part of their service.
Identificador único para referência cruzada
Extensões adicionais que não fazem parte do modelo de dados básico
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
The provider of the report should make a comment about each image included in the report.
.inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value
Conclusão clínica (interpretação) dos resultados
Need to be able to provide a conclusion that is not lost among the basic result data.
inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
Códigos da conclusão clínica dos resultados
Diagnosis codes provided as adjuncts to the report.
inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
"application/pdf" is recommended as the most reliable and interoperable in this context.
Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.