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ProfilesPTTransversais/PatientPTTRV.StructureDefinition.json
PatientPTTRV (Patient) | I | PatientPTCore | There are no (further) constraints on this element Element idPatient Information about an individual or animal receiving health care services Alternate namesSubjectOfCare Client Resident DefinitionDemographics and other administrative information about an individual or animal receiving care or other health-related services.
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id | Σ | 1..1 | id | There are no (further) constraints on this element Element idPatient.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | MetaPTCore | There are no (further) constraints on this element Element idPatient.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idPatient.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idPatient.language Language of the resource content DefinitionThe base language in which the resource is written. 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). IETF language tag
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idPatient.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. 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.
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contained | I | 0..* | Resource | There are no (further) constraints on this element Element idPatient.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. 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.
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extension | I | 0..0 | Extension | There are no (further) constraints on this element Element idPatient.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idPatient.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | Σ | 0..* | ExtensionIdentifierPTCore | There are no (further) constraints on this element Element idPatient.identifier An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Patients are almost always assigned specific numerical identifiers.
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id | 0..1 | id | There are no (further) constraints on this element Element idPatient.identifier.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPatient.identifier.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idPatient.identifier.use usual | official | temp | secondary | old (If known) DefinitionPropósito do identificador: official: O identificador considerado mais fiável para a identificação do item. temp: Um identificador temporário. secondary: Um identificador que foi atribuído para identificar o item em um contexto relativo, mas não pode usado em um contexto diferente. old: O identificador já não é considerado válido, mas pode ser relevante para fins de pesquisa. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
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type | Σ | 0..1 | CodeableConceptPTCoreBinding | There are no (further) constraints on this element Element idPatient.identifier.type Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Allows users to make use of identifiers when the identifier system is not known. Value Set: ExtensionIdentifierType ExtensionIdentifierType (extensible) Constraints
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id | 0..1 | id | There are no (further) constraints on this element Element idPatient.identifier.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPatient.identifier.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | Σ | 0..* | CodingPTCore | There are no (further) constraints on this element Element idPatient.identifier.type.coding A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
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id | 0..1 | id | Element idPatient.identifier.type.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. ..
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idPatient.identifier.type.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idPatient.identifier.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..0 | string | There are no (further) constraints on this element Element idPatient.identifier.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idPatient.identifier.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 1..1 | string | There are no (further) constraints on this element Element idPatient.identifier.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idPatient.identifier.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 1..1 | string | There are no (further) constraints on this element Element idPatient.identifier.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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system | Σ | 0..1 | uri | There are no (further) constraints on this element Element idPatient.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Para sistemas geridos pela SPMS o system tem de seguir a seguinte estrutura: http://spms.min-saude.pt/<sistema>/identifiers/<identifier-id>
General http://www.acme.com/identifiers/patient Mappings
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idPatient.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | PeriodPTCore | There are no (further) constraints on this element Element idPatient.identifier.period Time range defined by start and end date/time Alternate namesPeriod DefinitionA time period defined by a start and end date and optionally time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..0 | Reference(OrganizationPTCore) | There are no (further) constraints on this element Element idPatient.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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active | Σ ?! | 0..0 | boolean | There are no (further) constraints on this element Element idPatient.active Whether this patient's record is in active use DefinitionIndicação do estado da inscrição do utente nos cuidados de saúde primários. Need to be able to mark a patient record as not to be used because it was created in error. If a record is inactive, and linked to an active record, then future patient/record updates should occur on the other patient. This resource is generally assumed to be active if no value is provided for the active element
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name | Σ | 0..* | HumanNamePTCore | There are no (further) constraints on this element Element idPatient.name Name of a human - parts and usage DefinitionA human's name with the ability to identify parts and usage. Need to be able to track the patient by multiple names. Examples are your official name and a partner name. Names may be changed, or repudiated, or people may have different names in different contexts. Names may be divided into parts of different type that have variable significance depending on context, though the division into parts does not always matter. With personal names, the different parts might or might not be imbued with some implicit meaning; various cultures associate different importance with the name parts and the degree to which systems must care about name parts around the world varies widely.
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telecom | Σ I | 0..0 | ContactPointPTCore | There are no (further) constraints on this element Element idPatient.telecom Details of a Technology mediated contact point (phone, fax, email, etc.) DefinitionDetails for all kinds of technology mediated contact points for a person or organization, including telephone, email, etc. People have (primary) ways to contact them in some way such as phone, email. A Patient may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently and also to help with identification. The address might not go directly to the individual, but may reach another party that is able to proxy for the patient (i.e. home phone, or pet owner's phone).
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gender | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idPatient.gender male | female | other | unknown DefinitionSexo administrativo Needed for identification of the individual, in combination with (at least) name and birth date. The gender might not match the biological sex as determined by genetics or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than male and female, though the vast majority of systems and contexts only support male and female. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific sex or gender aspect of interest (anatomical, chromosomal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosomal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overridable error, not a "hard" error. See the Patient Gender and Sex section for additional information about communicating patient gender and sex. The gender of a person used for administrative purposes.
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birthDate | Σ | 0..1 | date | There are no (further) constraints on this element Element idPatient.birthDate The date of birth for the individual DefinitionData de nascimento do indivíduo. Age of the individual drives many clinical processes. At least an estimated year should be provided as a guess if the real DOB is unknown There is a standard extension "patient-birthTime" available that should be used where Time is required (such as in maternity/infant care systems).
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deceased[x] | Σ ?! | 0..0 | There are no (further) constraints on this element Element idPatient.deceased[x] Indicates if the individual is deceased or not DefinitionIndicação se utente falecido The fact that a patient is deceased influences the clinical process. Also, in human communication and relation management it is necessary to know whether the person is alive. If there's no value in the instance, it means there is no statement on whether or not the individual is deceased. Most systems will interpret the absence of a value as a sign of the person being alive.
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address | Σ | 0..0 | AddressPTCore | There are no (further) constraints on this element Element idPatient.address An address expressed using postal conventions (as opposed to GPS or other location definition formats) DefinitionPara moradas nacionais é obrigatória a utilização da estrutura de moradas previstas pelos CTT. O atributo address.text será utilizado para descrição de morada de países terceiros e o atributo address.line terá de conter a estrutura da morada nacional definida pelos CTT, tendo de cumprir com a ordenação definida no line. May need to keep track of patient addresses for contacting, billing or reporting requirements and also to help with identification. Note: address is intended to describe postal addresses for administrative purposes, not to describe absolute geographical coordinates. Postal addresses are often used as proxies for physical locations (also see the Location resource).
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maritalStatus | 0..0 | CodeableConceptPTCoreBinding | There are no (further) constraints on this element Element idPatient.maritalStatus Concept - reference to a terminology or just text DefinitionIndicação do Estado Civil Most, if not all systems capture it. Value Set Name: Marital Status The domestic partnership status of a person.
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multipleBirth[x] | 0..0 | There are no (further) constraints on this element Element idPatient.multipleBirth[x] Whether patient is part of a multiple birth DefinitionIdentificação se utente faz parte de parto múltiplo ou indicação da ordem de nascimento For disambiguation of multiple-birth children, especially relevant where the care provider doesn't meet the patient, such as labs. Where the valueInteger is provided, the number is the birth number in the sequence. E.g. The middle birth in triplets would be valueInteger=2 and the third born would have valueInteger=3 If a boolean value was provided for this triplets example, then all 3 patient records would have valueBoolean=true (the ordering is not indicated).
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photo | I | 0..0 | AttachmentPTCore | There are no (further) constraints on this element Element idPatient.photo Content in a format defined elsewhere DefinitionFoto do Utente. Many EHR systems have the capability to capture an image of the patient. Fits with newer social media usage too. When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".
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contact | I | 0..0 | BackboneElement | There are no (further) constraints on this element Element idPatient.contact A contact party (e.g. guardian, partner, friend) for the patient DefinitionA contact party (e.g. guardian, partner, friend) for the patient. Need to track people you can contact about the patient. Contact covers all kinds of contact parties: family members, business contacts, guardians, caregivers. Not applicable to register pedigree and family ties beyond use of having contact.
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communication | 0..0 | BackboneElement | There are no (further) constraints on this element Element idPatient.communication A language which may be used to communicate with the patient about his or her health DefinitionIdentifica o idioma do utente. If a patient does not speak the local language, interpreters may be required, so languages spoken and proficiency are important things to keep track of both for patient and other persons of interest. If no language is specified, this implies that the default local language is spoken. If you need to convey proficiency for multiple modes, then you need multiple Patient.Communication associations. For animals, language is not a relevant field, and should be absent from the instance. If the Patient does not speak the default local language, then the Interpreter Required Standard can be used to explicitly declare that an interpreter is required.
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generalPractitioner | I | 0..0 | Reference(OrganizationPTCore | PractitionerPTCore | PractitionerRolePTCore) | There are no (further) constraints on this element Element idPatient.generalPractitioner Patient's nominated primary care provider Alternate namescareProvider DefinitionIdentificação da equipa de saúde familiar (médico de família e enfermeiro de família) e entidade de inscrição do utente nos Cuidados de Saúde Primários. This may be the primary care provider (in a GP context), or it may be a patient nominated care manager in a community/disability setting, or even organization that will provide people to perform the care provider roles. It is not to be used to record Care Teams, these should be in a CareTeam resource that may be linked to the CarePlan or EpisodeOfCare resources. Multiple GPs may be recorded against the patient for various reasons, such as a student that has his home GP listed along with the GP at university during the school semesters, or a "fly-in/fly-out" worker that has the onsite GP also included with his home GP to remain aware of medical issues. Jurisdictions may decide that they can profile this down to 1 if desired, or 1 per type. Reference(OrganizationPTCore | PractitionerPTCore | PractitionerRolePTCore) Constraints
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managingOrganization | Σ I | 0..0 | Reference(OrganizationPTCore) | There are no (further) constraints on this element Element idPatient.managingOrganization Organization that is the custodian of the patient record DefinitionIdentificação da entidade responsável pelo registo. Need to know who recognizes this patient record, manages and updates it. There is only one managing organization for a specific patient record. Other organizations will have their own Patient record, and may use the Link property to join the records together (or a Person resource which can include confidence ratings for the association).
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link | Σ ?! | 0..0 | BackboneElement | There are no (further) constraints on this element Element idPatient.link Link to another patient resource that concerns the same actual person DefinitionPatient.link tem de ser utilizado para identificar situações em que o recurso Patient e RelatedPerson correspondem ao mesmo utente: a) tem de ser referenciado o recurso RelatedPerson para identificar casos em que o utente em causa é também considerado como uma pessoa relacionada. A título exemplificado e sem perda de generalidade considere-se o cenário em que o utente xpto é mãe, filha e tia de diferentes outros utentes. O elemento Patient.link RelatedPerson, tem de ser utilizado para relacionar cada um dos RelatedPerson mãe, filha e tia com o Patient xpto; b) tem de ser referenciado o recurso Patient para identificar o registo histórico do utente ou diversos registos criados ao longo do tempo do mesmo utente; There are multiple use cases:
There is no assumption that linked patient records have mutual links.
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Binding
Path | Strength | ValueSet | Comment |
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Identifier.type | extensible | https://spms.min-saude.pt/iop/valueset/ExtensionIdentifierType | Value Set: ExtensionIdentifierType |
system
consultar Systems.Binding do FHIR Required
Path | strength | ValueSet |
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Patient: Identifier.use |
required |
IdentifierUse |
Identifiers Type
Estes Identificadores devem ser utilizados no elemento
identifier.type.coding[*]
system | code | display | text |
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http://terminology.hl7.org/CodeSystem/v2-0203 | HC | Health Card Number | Número Nacional do Utente |
http://terminology.hl7.org/CodeSystem/v2-0203 | PI | Patient Internal Identifier | Identificador Sequencial do Utente na Entidade |
Regras de implementação
Para além das constraints identificadas pelo FHIR para este recurso devem ser consideradas as constraints que identificamos na tabela infra.