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{
  "resourceType": "StructureDefinition",
  "id": "ClinicalImpressionPTCore",
  "url": "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore",
  "version": "1.0.0",
  "name": "ClinicalImpressionPTCore",
  "title": "Clinical Impression PT Core",
  "status": "draft",
  "date": "2024-06-19T16:32:00.2848052+00:00",
  "publisher": "SPMS",
  "contact": [
    {
      "name": "Interoperabilidade Semântica",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.spms.min-saude.pt"
        }
      ]
    }
  ],
  "fhirVersion": "4.3.0",
  "kind": "resource",
  "abstract": false,
  "type": "ClinicalImpression",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
  "derivation": "constraint",
  "differential": {
    "element": [
      {
        "id": "ClinicalImpression.meta",
        "path": "ClinicalImpression.meta",
        "definition": "Os metadados sobre o recurso.",
        "type": [
          {
            "code": "Meta",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MetaPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.identifier",
        "path": "ClinicalImpression.identifier",
        "definition": "Identificadores de negócio atribuídos a esta avaliação clínica pelo executor ou outros sistemas que permanecem constantes à medida que o recurso é atualizado e se propaga de servidor para servidor.",
        "type": [
          {
            "code": "Identifier",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/IdentifierPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.identifier.type.coding.id",
        "path": "ClinicalImpression.identifier.type.coding.id",
        "comment": "."
      },
      {
        "id": "ClinicalImpression.status",
        "path": "ClinicalImpression.status",
        "definition": "Identifica o status do fluxo de trabalho da avaliação."
      },
      {
        "id": "ClinicalImpression.statusReason",
        "path": "ClinicalImpression.statusReason",
        "definition": "O motivo do estado atual do ClinicalImpression.",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.code",
        "path": "ClinicalImpression.code",
        "definition": "Categoriza o tipo de avaliação clínica realizada.",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.description",
        "path": "ClinicalImpression.description",
        "definition": "Um resumo do contexto e/ou causa da avaliação – por que/onde ela foi realizada e quais eventos/status do paciente a motivaram."
      },
      {
        "id": "ClinicalImpression.subject",
        "path": "ClinicalImpression.subject",
        "definition": "O utente ou grupo de indivíduos avaliados como parte deste registro.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Patient",
              "http://hl7.org/fhir/StructureDefinition/Group",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/GroupPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PatientPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.encounter",
        "path": "ClinicalImpression.encounter",
        "definition": "O Encounter durante o qual este ClinicalImpression foi criado ou ao qual a criação deste registo está fortemente associada.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Encounter",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/EncounterPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.effective[x]",
        "path": "ClinicalImpression.effective[x]",
        "definition": "O momento ou período durante o qual o assunto foi avaliado."
      },
      {
        "id": "ClinicalImpression.date",
        "path": "ClinicalImpression.date",
        "definition": "Indica quando a documentação da avaliação foi concluída."
      },
      {
        "id": "ClinicalImpression.assessor",
        "path": "ClinicalImpression.assessor",
        "definition": "O médico que realiza a avaliação.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Practitioner",
              "http://hl7.org/fhir/StructureDefinition/PractitionerRole",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PractitionerPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PractitionerRolePTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.previous",
        "path": "ClinicalImpression.previous",
        "definition": "Uma referência à última avaliação realizada neste paciente",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.problem",
        "path": "ClinicalImpression.problem",
        "definition": "Uma lista dos problemas/condições relevantes para um paciente.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Condition",
              "http://hl7.org/fhir/StructureDefinition/AllergyIntolerance",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ConditionPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/AllergyIntolerancePTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.investigation",
        "path": "ClinicalImpression.investigation",
        "definition": "Um ou mais conjuntos de investigações (sinais, sintomas, etc.)."
      },
      {
        "id": "ClinicalImpression.investigation.code",
        "path": "ClinicalImpression.investigation.code",
        "definition": "Um nome/código para o grupo (\"conjunto\") de investigações.",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.investigation.item",
        "path": "ClinicalImpression.investigation.item",
        "definition": "Um registo de uma investigação específica que foi realizada.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Observation",
              "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse",
              "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory",
              "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
              "http://hl7.org/fhir/StructureDefinition/RiskAssessment",
              "http://hl7.org/fhir/StructureDefinition/ImagingStudy",
              "http://hl7.org/fhir/StructureDefinition/Media",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ObservationPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/QuestionnaireResponsePTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/FamilyMemberHistoryPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DiagnosticReportPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RiskAssessmentPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ImagingStudyPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MediaPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.protocol",
        "path": "ClinicalImpression.protocol",
        "definition": "Referência a um protocolo clínico específico publicado que foi seguido durante esta avaliação e/ou que fornece evidências que apoiam o diagnóstico."
      },
      {
        "id": "ClinicalImpression.summary",
        "path": "ClinicalImpression.summary",
        "definition": "Um resumo em texto das investigações e do diagnóstico."
      },
      {
        "id": "ClinicalImpression.finding",
        "path": "ClinicalImpression.finding",
        "definition": "Achados ou diagnósticos específicos que foram considerados prováveis ou relevantes para o tratamento contínuo."
      },
      {
        "id": "ClinicalImpression.finding.itemCodeableConcept",
        "path": "ClinicalImpression.finding.itemCodeableConcept",
        "definition": "Texto ou código específico para descoberta ou diagnóstico, que pode incluir condições descartadas ou resolvidas.",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.finding.itemReference",
        "path": "ClinicalImpression.finding.itemReference",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Condition",
              "http://hl7.org/fhir/StructureDefinition/Observation",
              "http://hl7.org/fhir/StructureDefinition/Media",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ConditionPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ObservationPTCore",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MediaPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.finding.basis",
        "path": "ClinicalImpression.finding.basis",
        "definition": "Quais investigações apoiam a descoberta ou o diagnóstico."
      },
      {
        "id": "ClinicalImpression.prognosisCodeableConcept",
        "path": "ClinicalImpression.prognosisCodeableConcept",
        "definition": "Estimativa do resultado provável.",
        "type": [
          {
            "code": "CodeableConcept",
            "profile": [
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.prognosisReference",
        "path": "ClinicalImpression.prognosisReference",
        "definition": "RiskAssessment que expressa o resultado provável.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/RiskAssessment",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RiskAssessmentPTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.supportingInfo",
        "path": "ClinicalImpression.supportingInfo",
        "definition": "Informações que apoiam a avaliação clínica.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Resource",
              "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ResourcePTCore"
            ]
          }
        ]
      },
      {
        "id": "ClinicalImpression.note",
        "path": "ClinicalImpression.note",
        "definition": "Também podem aparecer comentários sobre a impressão, normalmente registados após a impressão em si, por meio de notas suplementares do autor original."
      }
    ]
  }
}

name : ClinicalImpressionPTCore

{

}