Implementation Guide for Portuguese Use Cases

Immunization PT PS RMV

Tree view

Immunization	I		Immunization	There are no (further) constraints on this element Element id Immunization Short description Immunization event information Definition Describes the event of a patient being administered a vaccine or a record of an immunization as reported by a patient, a clinician or another party. Data type Immunization Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` Mappings rim: Entity. Role, or Act workflow: Event v2: VXU_V04 rim: SubstanceAdministration w5: clinical.medication
id	Σ	1..1	id	Element id Immunization.id Short description Logical id of this artifact Definition Key relativa ao registo de inoculação, que permite identificar unicamente os registos de inoculações entre sistemas. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type id
meta	Σ	0..1	Meta PT Core	There are no (further) constraints on this element Element id Immunization.meta Short description Metadata about the resource Definition The 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. Data type Meta PT Core Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Immunization.implicitRules Short description A set of rules under which this content was created Definition A 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. Comments 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. Data type uri Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a
language		0..1	codeBinding	There are no (further) constraints on this element Element id Immunization.language Short description Language of the resource content Definition The base language in which the resource is written. Comments 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). Data type code Binding IETF language tag Common Languages (preferred) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a
text		0..1	Narrative	There are no (further) constraints on this element Element id Immunization.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A 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. Comments 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. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A rim: Act.text?
contained	I	0..*	Resource	There are no (further) constraints on this element Element id Immunization.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Constraints dom-r4b: Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) Mappings rim: Entity. Role, or Act rim: N/A
extension	I	0..0	Extension	There are no (further) constraints on this element Element id Immunization.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Immunization.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May 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). Requirements 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
identifier		0..0	Extension Identifier PT Core	There are no (further) constraints on this element Element id Immunization.identifier Short description An identifier intended for computation Definition Identificadores da vacinação. Data type Extension Identifier PT Core Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier rim: .id cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/id
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id Immunization.status Short description completed \| entered-in-error \| not-done Definition Indica o estado atual do evento de vacinação, sendo geralmente utilizado para identificar quando a vacinação está, ou não, concluída. O estado "completed" indica que o evento já foi concluído; O estado "not-done" indica que o evento terminou antes de qualquer atividade para além da preparação; O estado "entered-in-error" indica que o registo não devia ter sido efetuado. Comments Will generally be set to show that the immunization has been completed or not done. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding x Immunization Status Codes (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a workflow: Event.status w5: FiveWs.status rim: statusCode
statusReason		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.statusReason Short description Concept - reference to a terminology or just text Definition Identifica o motivo pelo qual a vacinação não foi realizada, sendo utilizado quando o estado corresponde a “not-done”. Comments Value Set Name: ReasonVaccineNotAdministered Data type CodeableConcept PT Core Binding Reason not done https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.statusReason rim: .inboundRelationship[typeCode=SUBJ].source[classCode=CACT, moodCode=EVN].reasonCOde
vaccineCode	S Σ	1..1	CodeableConcept PT Core	There are no (further) constraints on this element Element id Immunization.vaccineCode Short description Concept - reference to a terminology or just text Definition Identifica a vacina que foi ou será administrada. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept PT Core Sliced: Unordered, Open, by id(Value) Binding x Vaccine Administered Value Set (example) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: RXA-5 rim: .code cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacturedMaterial/realmCode/code
vaccine	Σ	0..1	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.vaccineCode:vaccine Short description Concept - reference to a terminology or just text Definition Identifica a vacina que foi ou será administrada. Comments Value Set Name: Vaccine Data type CodeableConcept PT Core Binding Vaccine product administered https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: RXA-5 rim: .code cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacturedMaterial/realmCode/code
id		0..1	idFixed Value	There are no (further) constraints on this element Element id Immunization.vaccineCode:vaccine.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Fixed value vaccine Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Immunization.vaccineCode:vaccine.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
coding	Σ	0..*	Coding PT Core	There are no (further) constraints on this element Element id Immunization.vaccineCode:vaccine.coding Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data type Coding PT Core Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	1..1	string	There are no (further) constraints on this element Element id Immunization.vaccineCode:vaccine.text Short description Plain text representation of the concept Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
absentOrUnknownVaccination	Σ	0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.vaccineCode:absentOrUnknownVaccination Short description Concept - reference to a terminology or just text Definition Identifica quando não é conhecido o histórico de vacinação ou quando não há registo de vacinação. Comments Value Set Name: AbsentOrUnknownVaccination Data type CodeableConcept PT Core Binding Vaccine Absent or Unknown https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: RXA-5 rim: .code cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacturedMaterial/realmCode/code
immunoglobulin	Σ	0..1	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.vaccineCode:immunoglobulin Short description Concept - reference to a terminology or just text Definition Identifica a imunoglobulina que foi ou será administrada. Comments Value Set Name: Immunoglobulin Data type CodeableConcept PT Core Binding Immunoglobulin product administered https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: RXA-5 rim: .code cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacturedMaterial/realmCode/code
id		0..1	idFixed Value	There are no (further) constraints on this element Element id Immunization.vaccineCode:immunoglobulin.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Fixed value immunoglobulin Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Immunization.vaccineCode:immunoglobulin.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
coding	Σ	0..*	Coding PT Core	There are no (further) constraints on this element Element id Immunization.vaccineCode:immunoglobulin.coding Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data type Coding PT Core Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	1..1	string	There are no (further) constraints on this element Element id Immunization.vaccineCode:immunoglobulin.text Short description Plain text representation of the concept Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
patient	S Σ I	1..1	Reference(Patient PT PS SNC)	Element id Immunization.patient Short description Who was immunized Definition Identifica o utente a quem foi ou não administrada a vacina. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Patient PT PS SNC) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 rim: .partipication[ttypeCode=].role w5: FiveWs.subject
encounter	I	0..0	Reference(Encounter PT Core)	There are no (further) constraints on this element Element id Immunization.encounter Short description Encounter immunization was part of Definition Identifica o episódio associado ao ato de vacinação. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Encounter PT Core) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.context w5: FiveWs.context v2: PV1-19 rim: component->EncounterEvent
occurrence[x]	S Σ	1..1		There are no (further) constraints on this element Element id Immunization.occurrence[x] Short description Vaccine administration date Definition Data em que ocorreu a administração da vacina. Comments When immunizations are given a specific date and time should always be known. When immunizations are patient reported, a specific date might not be known. Although partial dates are allowed, an adult patient might not be able to recall the year a childhood immunization was given. An exact date is always preferable, but the use of the String data type is acceptable when an exact date is not known. A small number of vaccines (e.g. live oral typhoid vaccine) are given as a series of patient self-administered dose over a span of time. In cases like this, often, only the first dose (typically a provider supervised dose) is recorded with the occurrence indicating the date/time of the first dose. Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: RXA-3 rim: .effectiveTime cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/effectiveTime/value
occurrenceDateTime			dateTime	Data type dateTime
recorded		0..0	dateTime	There are no (further) constraints on this element Element id Immunization.recorded Short description When the immunization was first captured in the subject's record Definition Identifica a data na qual a vacinação foi registada pela primeira vez. Uma data ou data parcial ou data e hora, sendo o formato definido pela ISO8601. Se a hora e minutos forem especificados, descrição da time zone (UTC) DEVE ser preenchida. Os segundos devem ser fornecidos devido a restrições de tipo de esquema, mas podem ser preenchidos com zero. O horário "24:00" não é permitido. Formatos possíveis: ano; ano e mês; ano, mês e dia; YYYY-MM-DDThh:mm:ss+zz:zz - ano, mês, dia , hora, minutos , segundos e time zone. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a w5: FiveWs.recorded rim: .participation[typeCode=AUT].time
primarySource	Σ	0..0	boolean	There are no (further) constraints on this element Element id Immunization.primarySource Short description Indicates context the data was recorded in Definition Se Immunization.primarySource: TRUE. Indica que o conteúdo do registro se baseia em informações da pessoa que administrou a vacina. Se Immunization.primarySource: FALSE. Indica que o conteúdo do registo não é baseado na informação da pessoa que administrou e no elemento Immunization.reportOrigin pode ser indicado a pessoa que facultou a informação, quando conhecido. Comments Reflects the “reliability” of the content. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a w5: FiveWs.source v2: RXA-9 rim: immunization.uncertaintycode (if primary source=false, uncertainty=U)
reportOrigin		0..0	CodeableConcept PT Core	There are no (further) constraints on this element Element id Immunization.reportOrigin Short description Concept - reference to a terminology or just text Definition Identifica a fonte da informação registada. Este elemento não deve ser preenchido quando primarySource=true. Se Immunization.primarySource: FALSE. Indica que o conteúdo do registo não é baseado na informação da pessoa que administrou e no elemento Immunization.reportOrigin pode ser indicado a pessoa que facultou a informação, quando conhecido. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept PT Core Sliced: Unordered, Open, by id(Value) Binding x Immunization Origin Codes (example) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD w5: FiveWs.source v2: RXA-9 rim: .participation[typeCode=INF].role[classCode=PAT] (this syntax for self-reported) .participation[typeCode=INF].role[classCode=LIC] (this syntax for health care professional) .participation[typeCode=INF].role[classCode=PRS] (this syntax for family member)
location	I	0..0	Reference(Location PT PS)	Element id Immunization.location Short description Where immunization occurred Definition Identifica a localização física onde ocorreu a administração da vacina. Ex: Identificação da sala, gabinete, país. Requirements Se o país no qual a vacina foi administrada não for Portugal, TEM de ser indicado o país no elemento Immunization.location. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Location PT PS) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.location w5: FiveWs.where[x] v2: RXA-27 (or RXA-11, deprecated as of v2.7) rim: .participation[typeCode=LOC].COCT_MT240000UV
manufacturer	I	0..0	Reference(Organization PT Core)	There are no (further) constraints on this element Element id Immunization.manufacturer Short description Vaccine manufacturer Definition Identifica o fabricante da vacina. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Organization PT Core) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2: RXA-17 rim: .participation[typeCode=CSM].role[classCode=INST].scopedRole.scoper[classCode=ORG] cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacuturerOrganization/name
lotNumber		0..0	string	There are no (further) constraints on this element Element id Immunization.lotNumber Short description Vaccine lot number Definition Identifica o número do lote da vacina. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: RXA-15 rim: .participation[typeCode=CSM].role[classCode=INST].scopedRole.scoper[classCode=MMAT].id cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/consumable/manfacturedProduct/manufacturedMaterial/lotNumberText
expirationDate		0..0	date	There are no (further) constraints on this element Element id Immunization.expirationDate Short description Vaccine expiration date Definition Identifica a data de validade da vacina. Uma data ou data parcial. O formato é o definido pela ISO8601. A descrição da time zone (UTC) NÂO DEVE ser preenchida. Formatos possíveis: ano; ano e mês; ano, mês e dia. Data type date Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: RXA-16 rim: .participation[typeCode=CSM].role[classCode=INST].scopedRole.scoper[classCode=MMAT].expirationTime
site		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.site Short description Body site vaccine was administered Definition Identifica a parte do corpo onde foi administrada a vacina. Comments Value Set Name: AnatomicalSctruture Data type CodeableConcept PT Core Binding Body site vaccine was administered https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: RXR-2 rim: observation.targetSiteCode cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/approachSiteCode/code
route		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.route Short description Concept - reference to a terminology or just text Definition Identifica a via de administração da vacina. Comments Value Set Name: RouteOfAdministration Data type CodeableConcept PT Core Binding How vaccine entered body https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-da-medicacao (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: RXR-1 rim: .routeCode cda: ClinicalDocument/component/StructuredBody/component/section/entry/substanceAdministration/routeCode/code
doseQuantity	I	0..0	SimpleQuantity PT Core	There are no (further) constraints on this element Element id Immunization.doseQuantity Short description A measured or measurable amount Definition Identifica a quantidade total que foi administrada. Comments The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator. Data type SimpleQuantity PT Core Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` qty-3: If a code for the unit is present, the system SHALL also be present `code.empty() or system.exists()` sqty-1: The comparator is not used on a SimpleQuantity `comparator.empty()` Mappings rim: n/a v2: SN (see also Range) or CQ rim: PQ, IVL<PQ>, MO, CO, depending on the values v2: RXA-6 / RXA-7 rim: .doseQuantity
performer	Σ	0..1	BackboneElement	There are no (further) constraints on this element Element id Immunization.performer Short description Who performed event Definition Identifica a função associada a quem administrou a vacina. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a workflow: Event.performer v2: ORC-12 / RXA-10 rim: .participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]
id		0..1	id	There are no (further) constraints on this element Element id Immunization.performer.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Immunization.performer.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Immunization.performer.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained 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 can 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
function	Σ	0..1	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.performer.function Short description Concept - reference to a terminology or just text Definition Identifica a função associada a quem administrou a vacina: AP (Administering Provider): RP-PT (Recorder Provider) Comments Value Set: {{link:https://spms.min-saude.pt/iop/valueset/ExtensionImmunizationFunction}} Data type CodeableConcept PT Core Binding x Extension Immunization Function (extensible) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.performer.function rim: .participation.functionCode
actor	Σ I	1..1	Reference(Organization PT TRV)	Element id Immunization.performer.actor Short description Individual or organization who was performing Definition Quando function = AP - Identifica o profissional ou entidade referente à administração da vacina. Quando function = RP-PT - Identifica o profissional ou entidade referente à ação de registar/transcrever a vacina. Comments When the individual practitioner who performed the action is known, it is best to send. Data type Reference(Organization PT TRV) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer.actor w5: FiveWs.actor rim: .player
note	Σ	0..0	Annotation	There are no (further) constraints on this element Element id Immunization.note Short description Additional immunization notes Definition Informações adicionais da vacinação. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: N/A rim: Act workflow: Event.note v2: OBX-5 : OBX-3 = 48767-8 rim: note
reasonCode		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.reasonCode Short description Concept - reference to a terminology or just text Definition Identifica o motivo pelo qual a vacina foi administrada. Comments Value Set Name: VaccinationReason Data type CodeableConcept PT Core Sliced: Unordered, Open, by id(Value) Binding Why immunization occurred https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.reasonCode rim: [actionNegationInd=false].reasonCode
reasonReference	I	0..0	Reference(Condition PT Core \| Observation PT Core \| DiagnosticReport PT Core)	There are no (further) constraints on this element Element id Immunization.reasonReference Short description Why immunization occurred Definition Identifica o motivo pelo qual foi realizada a vacinação. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Condition PT Core \| Observation PT Core \| DiagnosticReport PT Core) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.reasonReference rim: N/A
isSubpotent	Σ ?!	0..0	boolean	There are no (further) constraints on this element Element id Immunization.isSubpotent Short description Dose potency Definition Indica se a vacina é subpotente. Comments Typically, the recognition of the dose being sub-potent is retrospective, after the administration (ex. notification of a manufacturer recall after administration). However, in the case of a partial administration (the patient moves unexpectedly and only some of the dose is actually administered), subpotency may be recognized immediately, but it is still important to record the event. Meaning when missing By default, a dose should be considered to be potent. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: RXA-20 = PA (partial administration) rim: N/A
subpotentReason		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.subpotentReason Short description Concept - reference to a terminology or just text Definition Identifica o motivo pelo qual a vacina é subpotente. Comments ValueSet Name: VaccinationSubpotentReason Data type CodeableConcept PT Core Binding The reason why a dose is considered to be subpotent. https://www.ctc.min-saude.pt/catalogos/vacinas (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: N/A
education	I	0..0	BackboneElement	There are no (further) constraints on this element Element id Immunization.education Short description Educational material presented to patient Definition Identifica o material educativo apresentado ao utente. Deve ser preenchido o elemento documentType ou reference. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` imm-1: One of documentType or reference SHALL be present `documentType.exists() or reference.exists()` Mappings rim: n/a rim: N/A
programEligibility		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.programEligibility Short description Concept - reference to a terminology or just text Definition Identifica a elegibilidade do utente para receber a vacina. Comments Value Set Name: ProgramEligibility Data type CodeableConcept PT Core Binding Patient eligibility for a vaccination program https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: OBX-5 : OBX-3 = 64994-7 rim: N/A
fundingSource		0..0	CodeableConcept PT CoreBinding	There are no (further) constraints on this element Element id Immunization.fundingSource Short description Concept - reference to a terminology or just text Definition Identifica a fonte de financiamento da vacina, permitindo a distinção entre vacinas gratuitas ou não no SNS. Comments Value Set Name: FundingSource Data type CodeableConcept PT Core Binding Funding source for the vaccine https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-administrativo (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: N/A
reaction		0..0	BackboneElement	There are no (further) constraints on this element Element id Immunization.reaction Short description Details of a reaction that follows immunization Definition Identifica a reação. Comments A reaction may be an indication of an allergy or intolerance and, if this is determined to be the case, it should be recorded as a new AllergyIntolerance resource instance as most systems will not query against past Immunization.reaction elements. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: OBX-3 rim: Observation[classCode=obs].code
protocolApplied		0..0	BackboneElement	There are no (further) constraints on this element Element id Immunization.protocolApplied Short description Protocol followed by the provider Definition Identifica o protocolo ou recomendação da vacinação, enquadrando o número da inoculação efetuada na recomendação nacional. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A

Binding

Path	Strength	ValueSet	Comment
Immunization.vaccineCode vaccine	required	https://www.ctc.min-saude.pt/catalogos/vacinas	Value Set Name: Vaccine
Immunization.vaccineCode immunoglobulin	required	https://www.ctc.min-saude.pt/catalogos/vacinas	Value Set Name: Immunoglobulin
Immunization.performer.function	extensible	https://spms.min-saude.pt/iop/valueset/ExtensionImmunizationFunction	Value Set: Extension Immunization Function

Path

Strength

ValueSet

Comment

Immunization.vaccineCode

vaccine

required

https://www.ctc.min-saude.pt/catalogos/vacinas

Value Set Name: Vaccine

Immunization.vaccineCode

immunoglobulin

required

https://www.ctc.min-saude.pt/catalogos/vacinas

Value Set Name: Immunoglobulin

Immunization.performer.function

extensible

https://spms.min-saude.pt/iop/valueset/ExtensionImmunizationFunction

Value Set: Extension Immunization Function

Para mais informações sobre a utilização do elemento system consultar Systems.

Binding do FHIR Required

Path	strength	ValueSet
Immunization.status	required	Immunization Status Codes

Identifiers Type

Estes Identificadores devem ser utilizados no elemento

identifier.type.coding[*]

Regras de implementação

Para além das constraints identificadas pelo FHIR para este recurso devem ser consideradas as constraints que identificamos na tabela infra.

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