Hoja Clinica -> Documento FHIR
Documentos FHIR
Debido a que la Hoja Clínica cumple con todas las condiciones para ser un documento clínico es decir :
- Ciclo de vida -> Persistente
- Comunción -> Entre Humanos
- Aspectos legales -> Legalemente Viable
- Origen -> Definido por precendentes
Por tanto debe la forma correcta de intercambiar los datos que posee la misma será mediante un documento FHIR. Este un bundle de tipo document, donde la primera entrada debe ser un composition, que es el que contiene los metadatos del documento, luego las siguientes entradas deben ser las de Patient, Organization, Practiotioner, Encounter y luego los recursos que detallen la historia del paciente.
Teniendo en cuenta el mapeo que se meustra en la siguiente tabla :
| Hoja Clinica |
Recurso FHIR |
| Exploración |
Observation |
| Diagnostico |
Condition |
| Plan de Actuación |
CarePlan |
| Pronostico |
RiskAssessment |
| Evolución |
ClinicalImpression |
El Bundle quedaría acorde a la siguiente forma :
| HojaClinicaBundle (Bundle) | | | http://hl7.org/fhir/StructureDefinition/Bundle | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Bundle |
| type | S | | Fixed Value | There are no (further) constraints on this element Element idFixed value |
| link | | ..0 | | There are no (further) constraints on this element Element id |
| entry | S | | | There are no (further) constraints on this element Element id |
| resource | | | | There are no (further) constraints on this element Element idShort description Hoja Clinica |
| resourceComposition | | | http://hl7.org/fhir/StructureDefinition/Composition | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Composition |
| resourcePatient | | | http://hl7.org/fhir/StructureDefinition/Patient | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Patient |
| resourceOrganization | | | http://hl7.org/fhir/StructureDefinition/Organization | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Organization |
| resourcePractitioner | | | http://hl7.org/fhir/StructureDefinition/Practitioner | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Practitioner |
| resourceEncounter | | | http://hl7.org/fhir/StructureDefinition/Encounter | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Encounter |
| resourceCondition | | | http://hl7.org/fhir/StructureDefinition/Condition | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Condition |
| resourceDiagnosticReport | | | http://hl7.org/fhir/StructureDefinition/DiagnosticReport | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/DiagnosticReport |
| resourceObservation | | | http://hl7.org/fhir/StructureDefinition/Observation | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Observation |
| resourceCarePlan | | | http://hl7.org/fhir/StructureDefinition/CarePlan | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/CarePlan |
| resourceClinicalImpression | | | http://hl7.org/fhir/StructureDefinition/ClinicalImpression | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/ClinicalImpression |
| resourceRiskAssessment | | | http://hl7.org/fhir/StructureDefinition/RiskAssessment | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/RiskAssessment |
| request | | ..0 | | There are no (further) constraints on this element Element id |
| response | | ..0 | | There are no (further) constraints on this element Element id |
| HojaClinicaBundle (Bundle) | | | http://hl7.org/fhir/StructureDefinition/Bundle | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Bundle |
| type | S | | Fixed Value | There are no (further) constraints on this element Element idFixed value |
| link | | ..0 | | There are no (further) constraints on this element Element id |
| entry | S | | | There are no (further) constraints on this element Element id |
| resource | | | | There are no (further) constraints on this element Element idShort description Hoja Clinica |
| resourceComposition | | | http://hl7.org/fhir/StructureDefinition/Composition | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Composition |
| resourcePatient | | | http://hl7.org/fhir/StructureDefinition/Patient | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Patient |
| resourceOrganization | | | http://hl7.org/fhir/StructureDefinition/Organization | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Organization |
| resourcePractitioner | | | http://hl7.org/fhir/StructureDefinition/Practitioner | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Practitioner |
| resourceEncounter | | | http://hl7.org/fhir/StructureDefinition/Encounter | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Encounter |
| resourceCondition | | | http://hl7.org/fhir/StructureDefinition/Condition | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Condition |
| resourceDiagnosticReport | | | http://hl7.org/fhir/StructureDefinition/DiagnosticReport | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/DiagnosticReport |
| resourceObservation | | | http://hl7.org/fhir/StructureDefinition/Observation | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/Observation |
| resourceCarePlan | | | http://hl7.org/fhir/StructureDefinition/CarePlan | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/CarePlan |
| resourceClinicalImpression | | | http://hl7.org/fhir/StructureDefinition/ClinicalImpression | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/ClinicalImpression |
| resourceRiskAssessment | | | http://hl7.org/fhir/StructureDefinition/RiskAssessment | There are no (further) constraints on this element Data type http://hl7.org/fhir/StructureDefinition/RiskAssessment |
| request | | ..0 | | There are no (further) constraints on this element Element id |
| response | | ..0 | | There are no (further) constraints on this element Element id |
Generación dinámica de documentos FHIR
Lo que se propone es la obtención de cada recurso de forma independiente, de tal forma que el desarrollo y la implementación se puede hacer de forma escalonada y finalmente cuando se precise este desarrollo se puede condensar toda la información en recursos de tipo composition que con su operación $document permiten que el servidor generé los documentos de forma dinámica a partir de los recursos independientes.