Ejemplo 1 (Resumen Completo)
Información Incluida
Cabecera
Identificador: 10501
Estado: FINAL
Tipo: Resumen Internacional de Paciente (IPS)
Fecha: 26/01/2018 14:30:00
Autor: Generado por Sistema HCE del Hospital Municipal Dr Angel Pintos
Título: Resumen del Paciente al 26-Enero-2018 14:30 hs.
Confidencialidad: N
Firmante
modo: LEGAL
Fecha/Hora: 26/01/2018 14:30
Responsable: Hospital Municipal Hospital Doctor Ángel Pintos
Teléfono: ph: +54 02281 43-5200
Domicilio: Amado Diab 270, B7300 Azul, Buenos Aires, Argentina
custodio:Hospital Municipal Hospital Doctor Ángel Pintos
Paciente: DNI-99999999 / Villareal Maria Victoria / 1969-11-01 (Femenino)
Información Clínica
Problemas:
| Problema | Estado | Verificación | Categoria | Severidad | Fecha Registro |
|---|---|---|---|---|---|
| Sofocones menopáusicos | Activo | Confirmado | Problema | Moderado | 10/2016 |
| Asma | Activo | Confirmado | Problema | Moderado | 10/2016 |
Medicación:
| Medicación | Forma | Dosis | Ruta | Estado | Periodo |
|---|---|---|---|---|---|
| Salbutamol 200 mcg/disparo | Disparo | 1/día | Respiratoria (inhalación) | Activo | 2015-03 |
Alergias:
| Descripción | Tipo | Categoria | Criticalidad | Fecha |
|---|---|---|---|---|
| Alergia a la penicilina | Alergia | Medicación | Alta | 2010 |
Vacunas:
| Descripción | Estado | Fecha | Protocolo/Serie | Organización | Ubicación |
|---|---|---|---|---|---|
| Vacuna antigripal trivalente | Completo | 2017 | Antigripal Esquema Personal de Salud/1 | Hospital Municipal Hospital Doctor Ángel Pintos | Hospital Municipal Hospital Doctor Ángel Pintos |
Ejemplo en JSON: https://simplifier.net/SaludDigital.ar/Ejemplo-IPS-AR-XML/~json
{ "resourceType": "Bundle", "id": "Resumen-HC-IPS-SaludDigital.ar", "meta": { "lastUpdated": "2018-01-26T14:30:00-03:00" }, "language": "es-AR", "entry": [ { "fullUrl": "http://hapi.fhir.org/baseR4/Composition/IPS-examples-Composition-01", "resource": { "id": "IPS-Composition-01", "subject": { "reference": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" }, "section": [ { "code": { "coding": [ { "system": "http://loinc.org", "display": "Problem list", "code": "11450-4" } ] }, "entry": [ { "reference": "http://hapi.fhir.org/baseR4/Condition/IPS-examples-Condition-01" } ], "title": "Problemas", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">asma (trastorno)</div>" } }, { "code": { "coding": [ { "system": "http://loinc.org", "display": "Medication use", "code": "10160-0" } ] }, "entry": [ { "reference": "http://hapi.fhir.org/baseR4/MedicationStatement/IPS-examples-MedicationStatement-01" } ], "title": "Medicamentos", "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <thead>\n <tr>\n <th>Medicamento</th>\n <th>Strength</th>\n <th>Forma</th>\n <th>Dosis</th>\n <th>Comentario</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>salbutamol (sustancia)</td>\n <td>200 mcg</td>\n <td>disparo</td>\n <td>uno por día</td>\n <td>tratamiento de asma</td>\n </tr>\n </tbody>\n </table>\n </div>" } }, { "code": { "coding": [ { "system": "http://loinc.org", "display": "Allergies and/or adverse reactions", "code": "48765-2" } ] }, "entry": [ { "reference": "http://hapi.fhir.org/baseR4/AllergyIntolerance/IPS-examples-AllergyIntolerance-01" } ], "title": "Alergias", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Alergia a penicilina (trastorno), criticidad alta, activo</div>" } }, { "title": "Vacunas", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">producto que contiene solamente antígeno de virus de la influenza (producto medicinal)</div>" }, "code": { "coding": [ { "system": "http://loinc.org", "display": "Immunization record", "code": "60484-3" } ] }, "entry": [ { "reference": "http://hapi.fhir.org/baseR4/Immunization/IPS-examples-Immunization-01" } ] } ], "resourceType": "Composition", "author": [ { "reference": "http://hapi.fhir.org/baseR4/Device/IPS-examples-Device-01" } ], "confidentiality": "N", "type": { "coding": [ { "system": "http://loinc.org", "display": "Patient Summary", "code": "60591-5" } ] }, "title": "Resumen del paciente al 26 de Enero de 2018, 14:30hs", "identifier": { "system": "http://hospitalPintos.org.ar/Composition", "value": "10501" }, "date": "2018-01-26T14:30:00-03:00", "meta": { "profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/composition-uv-ips" ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-Composition-01</p><p><b>meta</b>: </p><p><b>text</b>: </p><p><b>identifier</b>: 10501</p><p><b>status</b>: FINAL</p><p><b>type</b>: Patient Summary <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '60591-5' = 'Patient summary Document', given as 'Patient Summary'})</span></p><p><b>date</b>: 26/01/2018 14:30:00 PM</p><p><b>author</b>: <a href=\"#device_IPS-examples-Device-01\">Generated Summary: id: IPS-examples-Device-01; Sistema HCE del Hospital Municipal Dr Angel Pintos </a></p><p><b>title</b>: Patient Summary as of January 26, 2018 14:30</p><p><b>confidentiality</b>: N</p><blockquote><p><b>attester</b></p><p><b>mode</b>: LEGAL</p><p><b>time</b>: 26/01/2018 2:30:00 PM</p><p><b>party</b>: <a href=\"#organization_IPS-examples-Organization-01\">Generated Summary: id: IPS-examples-Organization-01; 14999912399913; active; Hospital Municipal Hospital Doctor Ángel Pintos </a></p></blockquote><p><b>custodian</b>: <a href=\"#organization_IPS-examples-Organization-01\">Generated Summary: id: IPS-examples-Organization-01; http://hospitalPintos.org.ar; active; name: Hospital Municipal Hospital Doctor Ángel Pintos / Dominio; ph: +54 02281 43-5200(WORK)</a></p></div>" }, "custodian": { "reference": "http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01" }, "attester": [ { "mode": "legal", "time": "2018-01-26T14:30:00-03:00", "party": { "reference": "http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01" } } ], "status": "final" } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01", "resource": { "id": "IPS-examples-Patient-01", "gender": "female", "telecom": [ { "system": "phone", "value": "44318113" } ], "birthDate": "1969-11-01", "identifier": [ { "system": "http://hospitalPintos.org.ar/Patient", "value": "9000022" }, { "system": "http://www.renaper.gob.ar/dni", "value": "99999999" } ], "resourceType": "Patient", "active": "true", "name": [ { "family": "Villareal", "given": [ "Maria", "Victoria" ], "_family": { "extension": [ { "url": "https://federador.msal.gob.ar/primer_apellido", "valueString": "Villareal" } ] }, "text": "Villareal Maria Victoria" } ] } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Device/IPS-examples-Device-01", "resource": { "resourceType": "Device", "id": "IPS-examples-Device-01", "identifier": [ { "system": "http://hospitalPintos.org.ar/Device", "value": "HCE_HtalPintos_v1.0" } ], "type": { "coding": [ { "system": "http://snomed.info/sct", "code": "462894001", "display": "software de aplicación de sistema de información de historias clínicas de pacientes (objeto físico)" } ] }, "owner": { "reference": "http://argentina.gob.ar/salud/refes/Organization/14999912399913" }, "deviceName": [ { "name": "Sistema HCE del Hospital Municipal Dr Angel Pintos", "type": "manufacturer-name" } ] } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Organization/IPS-examples-Organization-01", "resource": { "active": true, "address": [ { "use": "work", "line": [ "Amado Diab 270," ], "country": "Argentina", "city": "Azul", "postalCode": "B7300" } ], "id": "IPS-examples-Organization-01", "telecom": [ { "system": "phone", "value": "+54 02281 43-5200", "use": "work" } ], "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-Organization-01</p><p><b>text</b>: </p><p><b>identifier</b>: 14999912399913</p><p><b>active</b>: true</p><p><b>name</b>: Hospital Municipal Hospital Doctor Ángel Pintos</p><p><b>telecom</b>: ph: +54 02281 43-5200</p><p><b>address</b>: Amado Diab 270, B7300 Azul, Buenos Aires, Argentina</p></div>" }, "identifier": [ { "system": "http://argentina.gob.ar/salud/refes", "value": "14999912399913" }, { "system": "http://argentina.gob.ar/salud/bus-interoperabilidad/dominio", "value": "http://hospitalPintos.org.ar" } ], "resourceType": "Organization", "name": "Hospital Municipal Hospital Doctor Ángel Pintos" } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Condition/IPS-examples-Condition-01", "resource": { "id": "IPS-examples-Condition-01", "category": [ { "coding": [ { "system": "http://loinc.org", "display": "Problem", "code": "75326-9" } ] } ], "subject": { "reference": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" }, "onsetDateTime": "2016", "resourceType": "Condition", "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "code": "195967001", "system": "http://snomed.info/sct", "display": "asma (trastorno)" } ] }, "recordedDate": "2016-10", "meta": { "profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/condition-uv-ips" ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-Condition-01</p><p><b>meta</b>: </p><p><b>text</b>: </p><p><b>identifier</b>: c87bf51c-e53c-4bfe-b8b7-aa62bdd93002</p><p><b>clinicalStatus</b>: Active <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/condition-clinical code 'active' = 'Active)</span></p><p><b>verificationStatus</b>: Confirmed <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/condition-ver-status code 'confirmed' = 'Confirmed)</span></p><p><b>category</b>: Problem <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '75326-9' = 'Problem', given as 'Problem'})</span></p><p><b>severity</b>: Moderate <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'LA6751-7' = 'LA6751-7', given as 'Moderate'})</span></p><p><b>code</b>: Menopausal flushing (finding) <span style=\"background: LightGoldenRodYellow\">(Details : {SNOMED CT code '198436008' = 'Hot flush', given as 'Menopausal flushing (finding)'})</span></p><p><b>subject</b>: <a href=\"#patient_IPS-examples-Patient-01\">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p><p><b>recordedDate</b>: 01/10/2016</p></div>" }, "severity": { "coding": [ { "system": "http://loinc.org", "display": "Moderate", "code": "LA6751-7" } ] }, "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] } } }, { "fullUrl": "http://hapi.fhir.org/baseR4/MedicationStatement/IPS-examples-MedicationStatement-01", "resource": { "status": "active", "medicationReference": { "reference": "http://hapi.fhir.org/baseR4/Medication/IPS-examples-Medication-01" }, "dosage": [ { "route": { "coding": [ { "system": "http://snomed.info/sct", "display": "vía de administración en el tracto respiratorio (calificador)", "code": "447694001" } ] }, "timing": { "repeat": { "count": 1, "periodUnit": "d" } }, "doseAndRate": [ { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type", "display": "Ordered", "code": "ordered" } ] }, "doseQuantity": { "code": "732981002", "value": 1, "system": "http://snomed.info/sct", "unit": "disparo (unidad de presentación)" } } ] } ], "id": "IPS-examples-MedicationStatement-01", "effectivePeriod": { "start": "2015-03" }, "subject": { "reference": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" }, "meta": { "profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/medicationstatement-uv-ips" ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-MedicationStatement-01</p><p><b>meta</b>: </p><p><b>text</b>: </p><p><b>identifier</b>: b75f92cb-61d4-469a-9387-df5ef70d25f0</p><p><b>status</b>: ACTIVE</p><p><b>medication</b>: <a href=\"#medication_IPS-examples-Medication-01\">Generated Summary: id: IPS-examples-Medication-01; <span title=\"Codes: {http://snomed.info/sct 108774000}, {urn:oid:2.16.840.1.113883.2.4.4.1 99872}, {urn:oid:2.16.840.1.113883.2.4.4.7 2076667}\">Anastrozole (product)</span></a></p><p><b>subject</b>: <a href=\"#patient_IPS-examples-Patient-01\">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p><p><b>effective</b>: 01/03/2015 --> (ongoing)</p><p><b>dosage</b>: </p></div>" }, "resourceType": "MedicationStatement" } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Medication/IPS-examples-Medication-01", "resource": { "code": { "coding": [ { "system": "http://snomed.info/sct", "display": "producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico)", "code": "770301006" } ] }, "form": { "coding": [ { "system": "http://snomed.info/sct", "display": "disparo (unidad de presentación)", "code": "732981002" } ] }, "ingredient": [ { "code": { "coding": [ { "system": "http://snomed.info/sct", "display": "salbutamol (sustancia)", "code": "372897005" } ] }, "isActive": true, "strength": { "numerator": { "value": 200, "unit": "mcg" }, "denominator": { "value": 1, "unit": "disparo" } } } ], "id": "IPS-examples-Medication-01", "resourceType": "Medication", "meta": { "profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/medication-uv-ips" ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-Medication-01</p><p><b>meta</b>: </p><p><b>text</b>: </p><p><b>code</b>: producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico) <span style=\"background: LightGoldenRodYellow\">(Details : {SNOMED CT code '770301006' = 'producto que contiene exactamente salbutamol 200 microgramos/disparo en polvo de liberación convencional para administración por inhalación (fármaco de uso clínico)', given as 'Anastrozole (product)'};</span></p></div>" } } }, { "fullUrl": "http://hapi.fhir.org/baseR4/AllergyIntolerance/IPS-examples-AllergyIntolerance-01", "resource": { "category": [ "medication" ], "criticality": "high", "patient": { "reference": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" }, "id": "IPS-examples-AllergyIntolerance-01", "code": { "coding": [ { "system": "http://snomed.info/sct", "display": "alergia a la penicilina (trastorno)", "code": "91936005" } ] }, "meta": { "profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/allergyintolerance-uv-ips" ] }, "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: IPS-examples-AllergyIntolerance-01</p><p><b>meta</b>: </p><p><b>text</b>: </p><p><b>identifier</b>: 3a462598-009c-484a-965c-d6b24a821424</p><p><b>type</b>: ALLERGY</p><p><b>category</b>: MEDICATION</p><p><b>criticality</b>: HIGH</p><p><b>code</b>: Penicillin -class of antibiotic- (substance) <span style=\"background: LightGoldenRodYellow\">(Details : {SNOMED CT code '373270004' = 'Penicillin -class of antibiotic- (substance)', given as 'Penicillin -class of antibiotic- (substance)'})</span></p><p><b>patient</b>: <a href=\"#patient_IPS-examples-Patient-01\">Generated Summary: id: IPS-examples-Patient-01; 574687583; active; Martha DeLarosa ; ph: +31788700800(HOME); FEMALE; birthDate: 01/05/1972</a></p></div>" }, "resourceType": "AllergyIntolerance", "type": "allergy", "onsetDateTime": "2010" } }, { "fullUrl": "http://hapi.fhir.org/baseR4/Immunization/IPS-examples-Immunization-01", "resource": { "resourceType": "Immunization", "id": "IPS-examples-Immunization-01", "status": "completed", "notGiven": false, "vaccineCode": { "coding": [ { "system": "https://snomed.info/sct/11000221109/id/228100022110", "code": "1181000221105", "display": "producto que contiene solamente antígeno de virus de la influenza (producto medicinal)" } ] }, "patient": { "reference": "http://hapi.fhir.org/baseR4/Patient/IPS-examples-Patient-01" }, "occurrenceDateTime": "2017-05-22", "primarySource": true, "location": { "reference": "http://argentina.gob.ar/salud/refes/Location/14999912399913" }, "lotNumber": "649718", "expirationDate": "2017-12-22", "reasonCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "429060002", "display": "procedimiento para cumplir con el requerimiento ocupacional (procedimiento)" }, { "system": "http://saluddigital.ar/valueSet/NOMIVAC-condicion-code", "code": "17", "display": "Personal de Salud" } ] } ], "isSubpotent": false, "protocolApplied": [ { "series": "Antigripal Esquema Personal de Salud", "extension": [ { "url": "http://saluddigital.ar/fhir/esquema", "valueCoding": { "system": "http://saluddigital.ar/valueSet/NOMIVAC-esquema-code", "code": "81", "display": "Antigripal Esquema Personal de Salud" } } ], "targetDisease": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "6142004", "display": "gripe (trastorno)" } ] } ], "doseNumberPositiveInt": 1 } ] } } ], "type": "document", "identifier": { "system": "http://hospitalPintos.org.ar/Bundle", "value": "12000345" } }