{ "resourceType": "StructureDefinition", "id": "49ed3ca8-0c5c-400d-882e-ac4e790ad0a7", "meta": { "lastUpdated": "2020-11-13T19:28:16.45+00:00" }, "url": "http://esus.recife.pe.gov.br/StructureDefinition/Problem", "name": "Problem", "title": "Problem", "status": "active", "date": "2020-11-13T19:28:15.0312621+00:00", "purpose": "Uma condição que é descrita na estrutura Subjetivo-Objetivo-Avaliação e Plano (SOAP)", "fhirVersion": "4.0.1", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern" }, { "identity": "sct-concept", "uri": "http://snomed.info/conceptdomain", "name": "SNOMED CT Concept Domain Binding" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping" }, { "identity": "sct-attr", "uri": "http://snomed.org/attributebinding", "name": "SNOMED CT Attribute Binding" } ], "kind": "resource", "abstract": false, "type": "Condition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition", "derivation": "constraint", "differential": { "element": [ { "id": "Condition.identifier", "path": "Condition.identifier", "max": "0" }, { "id": "Condition.clinicalStatus", "path": "Condition.clinicalStatus", "definition": "Situação que o Diagnóstico/Problema se encontra no momento da informação. resolved: Resolvido active: Resolvendo active: Não resolvido null: Indeterminado", "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ConditionClinicalStatus" } ], "strength": "required", "description": "Estado da resolução de um diagnóstico ou problema.", "valueSet": "http://www.saude.gov.br/fhir/r4/ValueSet/BREstaadoResolucaoDiagnosticoProblema-1.0" } }, { "id": "Condition.clinicalStatus.coding", "path": "Condition.clinicalStatus.coding", "short": "Código definido por um sistema de terminologia", "definition": "Referência a um código definido por um sistema de terminologia." }, { "id": "Condition.clinicalStatus.coding.code", "path": "Condition.clinicalStatus.coding.code", "short": "Símbolo ou código de acordo com a terminologia", "definition": "Símbolo ou código de acordo com a terminologia\r\nReferência -\r\n http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoResolucaoDiagnosticoProblema-1.0" }, { "id": "Condition.clinicalStatus.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.clinicalStatus.text", "max": "0" }, { "id": "Condition.verificationStatus", "path": "Condition.verificationStatus", "max": "0" }, { "id": "Condition.category", "path": "Condition.category", "max": "0" }, { "id": "Condition.category.coding.system", "path": "Condition.category.coding.system", "fixedUri": "http://terminology.hl7.org/CodeSystem/condition-category" }, { "id": "Condition.category.coding.code", "path": "Condition.category.coding.code", "fixedCode": "problem-list-item" }, { "id": "Condition.category.coding.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.category.coding.display", "max": "0" }, { "id": "Condition.category.coding.userSelected", "path": "Condition.category.coding.userSelected", "max": "0" }, { "id": "Condition.category.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.category.text", "max": "0" }, { "id": "Condition.severity", "path": "Condition.severity", "max": "0" }, { "id": "Condition.code", "path": "Condition.code", "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ConditionKind" } ], "strength": "example", "valueSet": "http://www.saude.gov.br/fhir/r4/ValueSet/BRCIAP2-1.0" } }, { "id": "Condition.bodySite", "path": "Condition.bodySite", "max": "0" }, { "id": "Condition.subject", "path": "Condition.subject", "short": "Quem tem esta condição?", "definition": "Identifica o paciente portador da condição", "type": [ { "code": "Reference", "targetProfile": [ "http://esus.recife.pe.gov.br/StructureDefinition/Patient" ] } ] }, { "id": "Condition.subject.type", "path": "Condition.subject.type", "max": "0" }, { "id": "Condition.subject.identifier", "path": "Condition.subject.identifier", "definition": "Identificação do paciente. No caso da RNDS por CNS ou CPF." }, { "id": "Condition.subject.identifier.use", "path": "Condition.subject.identifier.use", "definition": "utilizar official para CNS ou CPF.", "fixedCode": "official" }, { "id": "Condition.subject.identifier.type", "path": "Condition.subject.identifier.type", "comment": "Identifica o tipo de documento conforme www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumentoIndividuo-1.0", "requirements": "Necessario informar o tipo de documento utilizado" }, { "id": "Condition.subject.identifier.type.coding", "path": "Condition.subject.identifier.type.coding", "min": 1, "max": "1" }, { "id": "Condition.subject.identifier.type.coding.system", "path": "Condition.subject.identifier.type.coding.system", "short": "Identificação do sistema terminológico", "definition": "Identificação do sistema terminológico conforme RNDS.", "comment": "Referência http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumentoIndividuo-1.0", "min": 1, "fixedUri": "http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumentoIndividuo-1.0" }, { "id": "Condition.subject.identifier.type.coding.code", "path": "Condition.subject.identifier.type.coding.code", "short": "Código conforme terminologia", "definition": "HC = CNS; TAX=CPF", "requirements": "Necessidade de informar qual o identifcador que está sendo utilizado", "min": 1 }, { "id": "Condition.subject.identifier.type.coding.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.subject.identifier.type.coding.display", "max": "0" }, { "id": "Condition.subject.identifier.type.coding.userSelected", "path": "Condition.subject.identifier.type.coding.userSelected", "max": "0" }, { "id": "Condition.subject.identifier.system", "path": "Condition.subject.identifier.system", "max": "0" }, { "id": "Condition.subject.identifier.period", "path": "Condition.subject.identifier.period", "max": "0" }, { "id": "Condition.subject.identifier.assigner", "path": "Condition.subject.identifier.assigner", "max": "0" }, { "id": "Condition.subject.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.subject.display", "max": "0" }, { "id": "Condition.encounter", "path": "Condition.encounter", "short": "Encounter que detectou a condição", "definition": "Referência ao Encounter que detectou a condição", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://esus.recife.pe.gov.br/StructureDefinition/Encounter" ] } ] }, { "id": "Condition.encounter.type", "path": "Condition.encounter.type", "max": "0" }, { "id": "Condition.encounter.identifier", "path": "Condition.encounter.identifier", "max": "0" }, { "id": "Condition.encounter.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.encounter.display", "max": "0" }, { "id": "Condition.onset[x]", "path": "Condition.onset[x]", "max": "0" }, { "id": "Condition.abatement[x]", "path": "Condition.abatement[x]", "max": "0" }, { "id": "Condition.recordedDate", "path": "Condition.recordedDate", "max": "0" }, { "id": "Condition.recorder", "path": "Condition.recorder", "max": "0" }, { "id": "Condition.asserter", "path": "Condition.asserter", "max": "0" }, { "id": "Condition.stage", "path": "Condition.stage", "short": "Estadiamento ou grau da doença", "definition": "estágio clínico de uma doença - inclui avaliações de diferentes tipos." }, { "id": "Condition.stage.summary", "path": "Condition.stage.summary", "max": "0" }, { "id": "Condition.stage.assessment", "path": "Condition.stage.assessment", "short": "Registro formal da avaliação", "definition": "Registro da avaliação do problema/diagnóstico. Faz referência a outros recursos que contém o registro - ClinicalImpression, Observation, DiagnosticReport e CarePlan. A estrutura SOAP - Observation utilizado para encaminhar S, O. ClinicalImpression para enviar A (Avaliação) e CarePlan para enviar o P (Plano).", "type": [ { "code": "Reference", "targetProfile": [ "http://esus.recife.pe.gov.br/StructureDefinition/Observation", "http://esus.recife.pe.gov.br/StructureDefinition/ClinicalImpression", "http://esus.recife.pe.gov.br/StructureDefinition/CarePlan" ] } ] }, { "id": "Condition.stage.assessment.type", "path": "Condition.stage.assessment.type", "max": "0" }, { "id": "Condition.stage.assessment.identifier", "path": "Condition.stage.assessment.identifier", "max": "0" }, { "id": "Condition.stage.assessment.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Condition.stage.assessment.display", "max": "0" }, { "id": "Condition.stage.type", "path": "Condition.stage.type", "max": "0" }, { "id": "Condition.evidence", "path": "Condition.evidence", "max": "0" }, { "id": "Condition.note", "path": "Condition.note", "max": "0" } ] } }