Narrativa gerada: StructureDefinition br-core-procedure Nome Bandeiras Card. Tipo Descrição e condicionalismos Procedure Procedure #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 Contained, inline Resources #xD; extension 0..* Extension Extension #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; instantiatesCanonical 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instâncias ou definições do protocolo FHIR #xD; instantiatesUri 0..* uri Instâncias externas do protocolo ou definições #xD; basedOn 0..* Reference(BRCoreCarePlan | BRCoreServiceRequest) Referência aos planos de cuidado/requisições para este procedimento #xD; partOf 0..* Reference(BRCoreProcedure | BRCoreObservation | br-core-medicationadministration) Referência aos procedimento/observação/administração de medicamentos asssociados a este procedimento #xD; status 1..1 code Código do status do procedimento #xD; statusReason 0..1 CodeableConcept Motivo para o status atual Vínculo: BRMotivoProcedimentoNaoRealizado (required) #xD; category 0..1 CodeableConcept Classificação do procedimento Vínculo: BRCategoriaProcedimento (required) #xD; code 1..1 CodeableConcept Código do procedimento Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRProcedimentosNacionais (required) #xD; subject 1..1 Reference(BRCorePatient) Referência ao paciente #xD; id 0..1 string Identificador exclusivo para referência entre elementos #xD; extension 0..* Extension Conteúdo adicional definido por implementações #xD; reference 0..1 string Referência literal, URL relativa, interna ou absoluta #xD; type 0..1 uri Tipo ao qual a referência se refere (por exemplo, Paciente) #xD; identifier 0..1 Identifier Referência lógica, quando a referência literal não é conhecida #xD; display 0..1 string Texto alternativo para o recurso #xD; encounter 0..1 Reference(br-core-encounter) Referência ao atendimento associado a este procedimento #xD; performed[x] 0..1 dateTime, Period, string, Age, Range Quando o procedimento foi realizado #xD; recorder 0..1 Reference(BRCorePatient | BRCoreRelatedPerson | BRCorePractitioner | BRCorePractitionerRole) Referência à paciente/pessoa/profissional que registrou o procedimento #xD; asserter 0..1 Reference(BRCorePatient | BRCoreRelatedPerson | BRCorePractitioner | BRCorePractitionerRole) Referência à paciente/pessoa/profissional que atestou este procedimento #xD; performer 1..1 BackboneElement Executante do procedimento #xD; id 0..1 string Identificador exclusivo para referência entre elementos #xD; extension 0..* Extension Conteúdo adicional definido por implementações #xD; modifierExtension 0..* Extension Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas #xD; function 0..1 CodeableConcept Função do executante #xD; actor 1..1 Reference(BRCorePatient | BRCoreRelatedPerson | BRCorePractitioner | BRCorePractitionerRole | BRCoreOrganization | Device) Referência do profispaciente/pessoa/profissional executante #xD; onBehalfOf 0..1 Reference(BRCoreOrganization) Referência à organização associada a este procedimento #xD; location 0..1 Reference(br-core-location) Referência ao local de execução do procedimento #xD; reasonCode 0..* CodeableConcept Motivo da realização do procedimento Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRProblemaDiagnostico (preferred) #xD; reasonReference 0..* Reference(BRCoreCondition | BRCoreObservation | BRCoreProcedure | BRCoreDiagnosticReport | DocumentReference) Referência à condição, observação, procedimento, relatório diagnóstico, documento clínico associado ao procedimento #xD; bodySite 0..* CodeableConcept Local anatômico associado ao procedimento Vínculo: SNOMEDCTBodyStructures (preferred) #xD; outcome 0..1 CodeableConcept Resultado do procedimento Vínculo: BRDesfechoProcedimento (required) #xD; report 0..* Reference(BRCoreDiagnosticReport | DocumentReference | br-core-composition) Referência ao documento/relatório resultantes deste procedimento #xD; complication 0..* CodeableConcept Complicações deste procedimento Vínculo: https://terminologia.saude.gov.br/fhir/ValueSet/BRProblemaDiagnostico (required) #xD; complicationDetail 0..* Reference(BRCoreCondition) Referência às condições resultantes das complicações dete procedimento #xD; followUp 0..* CodeableConcept Instruções para acompanhamento #xD; note 0..* Annotation Informações adicionais sobre o procedimento #xD; focalDevice 0..* BackboneElement Dispositivo manipulado, implantado ou removido #xD; id 0..1 string Identificador exclusivo para referência entre elementos #xD; extension 0..* Extension Conteúdo adicional definido por implementações #xD; modifierExtension 0..* Extension Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas #xD; action 0..1 CodeableConcept Código do tipo de alteração no dispositivo durante o procedimento #xD; manipulated 1..1 Reference(Device) Referência ao dispositivo alterado neste procedimento #xD; usedReference 0..* Reference(Device | br-core-medication | Substance) Referência ao dispositivo/medicamento/substância utilizados durante o procedimento #xD; usedCode 0..* CodeableConcept Tipo de dispositivos utilizados durante o procedimento #xD; Documentação para este formato
Este recurso descreve uma ação que é ou foi realizada em ou para um paciente. Pode ser uma intervenção física como uma operação, ou menos invasiva como serviços de longo prazo, aconselhamento ou hipnoterapia
An action that is being or was performed on a patient
An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.
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
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 Person resource instances might share the same social insurance number.
Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.
Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4
Instâncias ou definições do protocolo FHIR
Instâncias externas do protocolo ou definições
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Referência aos planos de cuidado/requisições para este procedimento
.outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
Referência aos procedimento/observação/administração de medicamentos asssociados a este procedimento
The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).
.inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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
A code specifying the state of the procedure.
This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
Classificação do procedimento. Exemplo: um código que classifica um procedimento para fins de pesquisa, classificação e exibição
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
0..1 to account for primarily narrative only resources.
Identificador exclusivo para referência entre elementos
Extensions are always sliced by (at least) url
Conteúdo adicional definido por implementações
Referência literal, URL relativa, interna ou absoluta
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 ao qual a referência se refere (por exemplo, Paciente)
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).
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 associado a este procedimento
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.
.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
Referência à paciente/pessoa/profissional que registrou o procedimento
Referência à paciente/pessoa/profissional que atestou este procedimento
Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Allows disambiguation of the types of involvement of different performers.
A code that identifies the role of a performer of the procedure.
Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25
Referência do profispaciente/pessoa/profissional executante
A reference to Device supports use cases, such as pacemakers.
Referência à organização associada a este procedimento
Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.
Referência ao local de execução do procedimento
Ties a procedure to where the records are likely kept.
Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Referência à condição, observação, procedimento, relatório diagnóstico, documento clínico associado ao procedimento
It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Local anatômico associado ao procedimento
If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [procedure-targetbodystructure](http://hl7.org/fhir/R4/extension-procedure-targetbodystructure.html).
If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
Referência ao documento/relatório resultantes deste procedimento
There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
.outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
Referência às condições resultantes das complicações dete procedimento
This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.
Specific follow up required for a procedure e.g. removal of sutures.
.outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
Informações adicionais sobre o procedimento
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
Dispositivo manipulado, implantado ou removido
Código do tipo de alteração no dispositivo durante o procedimento
A kind of change that happened to the device during the procedure.
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
Referência ao dispositivo alterado neste procedimento
Referência ao dispositivo/medicamento/substância utilizados durante o procedimento
For devices actually implanted or removed, use Procedure.device.
.participation[typeCode=DEV].role[classCode=MANU] or .participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
Tipo de dispositivos utilizados durante o procedimento
Codes describing items used during a procedure.