{ "resourceType": "StructureDefinition", "id": "br-core-vitalsigns", "url": "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-vitalsigns", "name": "br-core-vitalsigns", "status": "active", "description": "Este perfil é baseado no perfil [VitalSigns](http://hl7.org/fhir/R4/observation-vitalsigns.html) e define restrições adicionais no recurso Observation para representar Observation de sinais vitais. Ele especifica quais elementos principais, extensões, vocabulários e conjuntos de valores **DEVEM** estar presentes no recurso e restringe como os elementos são usados.", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "Observation", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/vitalsigns", "derivation": "constraint", "snapshot": { "element": [ { "id": "Observation", "path": "Observation", "short": "FHIR Vital Signs Profile", "definition": "The FHIR Vitals Signs profile sets minimum expectations for the Observation Resource to record, search and fetch the vital signs associated with a patient.", "comment": "Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.", "alias": [ "Vital Signs", "Measurement", "Results", "Tests" ], "min": 0, "max": "*", "base": { "path": "Observation", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "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", "expression": "contained.where((('#'+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(canonical) = '#').exists()).not()).trace('unmatched', id).empty()", "xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "xpath": "exists(f:text/h:div)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:security))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "obs-7", "severity": "error", "human": "If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present", "expression": "value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()", "xpath": "not(f:*[starts-with(local-name(.), 'value')] and (for $coding in f:code/f:coding return f:component/f:code/f:coding[f:code/@value=$coding/f:code/@value] [f:system/@value=$coding/f:system/@value]))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" }, { "key": "obs-6", "severity": "error", "human": "dataAbsentReason SHALL only be present if Observation.value[x] is not present", "expression": "dataAbsentReason.empty() or value.empty()", "xpath": "not(exists(f:dataAbsentReason)) or (not(exists(*[starts-with(local-name(.), 'value')])))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" }, { "key": "vs-2", "severity": "error", "human": "If there is no component or hasMember element then either a value[x] or a data absent reason must be present.", "expression": "(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())", "xpath": "f:component or f:memberOF or f:*[starts-with(local-name(.), 'value')] or f:dataAbsentReason", "source": "http://hl7.org/fhir/StructureDefinition/vitalsigns" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity|" }, { "identity": "v2", "map": "OBX" }, { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Observation.id", "path": "Observation.id", "short": "Identificador lógico deste artefato", "definition": "Identificador lógico deste artefato", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "isSummary": true }, { "id": "Observation.meta", "path": "Observation.meta", "short": "Metadados sobre o recurso", "definition": "Metadados sobre o recurso", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.implicitRules", "path": "Observation.implicitRules", "short": "URI(s) sob as quais este recurso é conhecido", "definition": "Um ou mais códigos que servem para identificar o tipo de recurso", "comment": "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.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.language", "path": "Observation.language", "short": "Linguagem do recurso", "definition": "A linguagem humana natural do recurso", "comment": "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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "preferred", "description": "A human language.", "valueSet": "http://hl7.org/fhir/ValueSet/languages" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.text", "path": "Observation.text", "short": "Texto narrativo, 72 caracteres para resumo", "definition": "Um texto narrativo resumindo as informações do recurso", "comment": "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.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "Observation.contained", "path": "Observation.contained", "short": "Recursos contidos", "definition": "Recursos contidos no recurso", "comment": "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.extension", "path": "Observation.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensões adicionais", "definition": "Extensões adicionais que não fazem parte do modelo base", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.modifierExtension", "path": "Observation.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensões adicionais que não podem ser ignoradas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "comment": "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.", "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.identifier", "path": "Observation.identifier", "short": "Identificadores externos para este recurso", "definition": "Identificadores externos para este recurso", "requirements": "Allows observations to be distinguished and referenced.", "min": 0, "max": "*", "base": { "path": "Observation.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "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]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "OBX.21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 2) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4." }, { "identity": "rim", "map": "id" } ] }, { "id": "Observation.basedOn", "path": "Observation.basedOn", "short": "Referência ao pedido ou ao plano de tratamento que gerou este recurso", "definition": "Referência ao pedido ou ao plano de tratamento que gerou este recurso", "comment": "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.", "requirements": "Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.", "alias": [ "Fulfills" ], "min": 0, "max": "*", "base": { "path": "Observation.basedOn", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-careplan", "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationrequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-servicerequest" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.basedOn" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[moodCode=EVN]" } ] }, { "id": "Observation.partOf", "path": "Observation.partOf", "short": "Referência ao evento do qual este recurso faz parte", "definition": "Referência ao evento do qual este recurso faz parte", "comment": "To link an Observation to an Encounter use `encounter`. See the [Notes](observation.html#obsgrouping) below for guidance on referencing another Observation.", "alias": [ "Container" ], "min": 0, "max": "*", "base": { "path": "Observation.partOf", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationadministration", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationdispense", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationstatement", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-procedure", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-immunization", "http://hl7.org/fhir/StructureDefinition/ImagingStudy" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.partOf" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "Observation.status", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "path": "Observation.status", "short": "Status atual da observação", "definition": "active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken", "comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.", "requirements": "Need to track the status of individual results. Some results are finalized before the whole report is finalized.", "min": 1, "max": "1", "base": { "path": "Observation.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isModifier": true, "isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Status" } ], "strength": "required", "description": "Codes providing the status of an observation.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-status|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "sct-concept", "map": "< 445584004 |Report by finality status|" }, { "identity": "v2", "map": "OBX-11" }, { "identity": "rim", "map": "status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of \"revise\"" } ] }, { "id": "Observation.category", "path": "Observation.category", "slicing": { "discriminator": [ { "type": "value", "path": "coding.code" }, { "type": "value", "path": "coding.system" } ], "ordered": false, "rules": "open" }, "short": "Categoria de alto nível da observação", "definition": "Categoria de alto nível da observação", "comment": "In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.", "requirements": "Used for filtering what observations are retrieved and displayed.", "min": 1, "max": "*", "base": { "path": "Observation.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "strength": "preferred", "description": "Codes for high level observation categories.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-category" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" } ] }, { "id": "Observation.category:VSCat", "path": "Observation.category", "sliceName": "VSCat", "short": "Classificação do tipo de observação", "definition": "Classificação do tipo de observação", "comment": "In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.", "requirements": "Used for filtering what observations are retrieved and displayed.", "min": 1, "max": "1", "base": { "path": "Observation.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "strength": "preferred", "description": "Codes for high level observation categories.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-category" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" } ] }, { "id": "Observation.category:VSCat.id", "path": "Observation.category.id", "representation": [ "xmlAttr" ], "short": "Identificador exclusivo para referência entre elementos", "definition": "Identificador exclusivo para referência entre elementos", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.category:VSCat.extension", "path": "Observation.category.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Conteúdo adicional definido por implementações", "definition": "Conteúdo adicional definido por implementações", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.category:VSCat.coding", "path": "Observation.category.coding", "short": "Código definido por uma terminologia", "definition": "Código definido por uma terminologia", "comment": "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. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 1, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "Observation.category:VSCat.coding.id", "path": "Observation.category.coding.id", "representation": [ "xmlAttr" ], "short": "Identificador exclusivo para referência entre elementos", "definition": "Identificador exclusivo para referência entre elementos", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.category:VSCat.coding.extension", "path": "Observation.category.coding.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Conteúdo adicional definido por implementações", "definition": "Conteúdo adicional definido por implementações", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.category:VSCat.coding.system", "path": "Observation.category.coding.system", "short": "Identidade do sistema de terminologia", "definition": "Identidade do sistema de terminologia", "comment": "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.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "base": { "path": "Coding.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "fixedUri": "http://terminology.hl7.org/CodeSystem/observation-category", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" }, { "identity": "orim", "map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem" } ] }, { "id": "Observation.category:VSCat.coding.version", "path": "Observation.category.coding.version", "short": "Versão do sistema, se relevante", "definition": "Versão do sistema, se relevante", "comment": "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.", "min": 0, "max": "1", "base": { "path": "Coding.version", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" }, { "identity": "orim", "map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion" } ] }, { "id": "Observation.category:VSCat.coding.code", "path": "Observation.category.coding.code", "short": "Símbolo na sintaxe definida pelo sistema", "definition": "Símbolo na sintaxe definida pelo sistema", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "base": { "path": "Coding.code", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "fixedCode": "vital-signs", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" }, { "identity": "orim", "map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code" } ] }, { "id": "Observation.category:VSCat.coding.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Observation.category.coding.display", "short": "Representação definida pelo sistema", "definition": "Representação definida pelo sistema", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "base": { "path": "Coding.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" }, { "identity": "orim", "map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName" } ] }, { "id": "Observation.category:VSCat.coding.userSelected", "path": "Observation.category.coding.userSelected", "short": "Se a codificação foi escolhida diretamente pelo usuário", "definition": "Se a codificação foi escolhida diretamente pelo usuário", "comment": "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.", "requirements": "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.", "min": 0, "max": "1", "base": { "path": "Coding.userSelected", "min": 0, "max": "1" }, "type": [ { "code": "boolean" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" }, { "identity": "orim", "map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]" } ] }, { "id": "Observation.category:VSCat.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Observation.category.text", "short": "Representação em texto simples do conceito", "definition": "Representação em texto simples do conceito", "comment": "Very often the text is the same as a displayName of one of the codings.", "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.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "Observation.code", "path": "Observation.code", "short": "Códigos dos resultados de sinais vitais do C-CDA", "definition": "Códigos dos resultados de sinais vitais do C-CDA", "comment": "*All* code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.", "requirements": "5. SHALL contain exactly one [1..1] code, where the @code SHOULD be selected from ValueSet HITSP Vital Sign Result Type 2.16.840.1.113883.3.88.12.80.62 DYNAMIC (CONF:7301).", "alias": [ "Name" ], "min": 1, "max": "1", "base": { "path": "Observation.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "VitalSigns" } ], "strength": "extensible", "description": "This identifies the vital sign result type.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-vitalsignresult" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR < 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" }, { "identity": "sct-attr", "map": "116680003 |Is a|" } ] }, { "id": "Observation.subject", "path": "Observation.subject", "short": "De quem ou do que trata a observação", "definition": "De quem ou do que trata a observação", "comment": "One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.", "requirements": "Observations have no value if you don't know who or what they're about.", "min": 1, "max": "1", "base": { "path": "Observation.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-patient" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": "participation[typeCode=RTGT]" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "Observation.focus", "path": "Observation.focus", "short": "Sobre o que é a observação, quando não é sobre o subject do registro", "definition": "Sobre o que é a observação, quando não é sobre o subject do registro", "comment": "Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., \"Blood Glucose\") and does not need to be represented separately using this element. Use `specimen` if a reference to a specimen is required. If a code is required instead of a resource use either `bodysite` for bodysites or the standard extension [focusCode](extension-observation-focuscode.html).", "min": 0, "max": "*", "base": { "path": "Observation.focus", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "participation[typeCode=SBJ]" }, { "identity": "w5", "map": "FiveWs.subject" } ] }, { "id": "Observation.encounter", "path": "Observation.encounter", "short": "Atendimento no qual a observação foi feita", "definition": "Atendimento no qual a observação foi feita", "comment": "This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).", "requirements": "For some observations it may be important to know the link between an observation and a particular encounter.", "alias": [ "Context" ], "min": 0, "max": "1", "base": { "path": "Observation.encounter", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-encounter" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.context" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "v2", "map": "PV1" }, { "identity": "rim", "map": "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" } ] }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "short": "Tempo ou período de tempo clinicamente relevante para os sinais vitais", "definition": "Tempo ou período de tempo clinicamente relevante para os sinais vitais", "comment": "At least a date should be present unless this observation is a historical report. For recording imprecise or \"fuzzy\" times (For example, a blood glucose measurement taken \"after breakfast\") use the [Timing](datatypes.html#timing) datatype which allow the measurement to be tied to regular life events.", "requirements": "Knowing when an observation was deemed true is important to its relevance as well as determining trends.", "alias": [ "Occurrence" ], "min": 1, "max": "1", "base": { "path": "Observation.effective[x]", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1", "vs-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "vs-1", "severity": "error", "human": "if Observation.effective[x] is dateTime and has a value then that value shall be precise to the day", "expression": "($this as dateTime).toString().length() >= 8", "xpath": "f:effectiveDateTime[matches(@value, '^\\d{4}-\\d{2}-\\d{2}')]", "source": "http://hl7.org/fhir/StructureDefinition/vitalsigns" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.done[x]" }, { "identity": "v2", "map": "OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)" }, { "identity": "rim", "map": "effectiveTime" } ] }, { "id": "Observation.issued", "path": "Observation.issued", "short": "Data ou hora em que esta versão da observação ficou disponível", "definition": "Data ou hora em que esta versão da observação ficou disponível", "comment": "For Observations that don’t require review and verification, it may be the same as the [`lastUpdated` ](resource-definitions.html#Meta.lastUpdated) time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the `lastUpdated` time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again.", "min": 1, "max": "1", "base": { "path": "Observation.issued", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "v2", "map": "OBR.22 (or MSH.7), or perhaps OBX-19 (depends on who observation made)" }, { "identity": "rim", "map": "participation[typeCode=AUT].time" } ] }, { "id": "Observation.performer", "path": "Observation.performer", "short": "O responsável pela observação", "definition": "O responsável pela observação", "comment": "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.", "requirements": "May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.", "min": 0, "max": "*", "base": { "path": "Observation.performer", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-practitioner", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-practitionerrole", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-organization", "http://hl7.org/fhir/StructureDefinition/CareTeam", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-patient", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-relatedperson" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.actor" }, { "identity": "v2", "map": "OBX.15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO'" }, { "identity": "rim", "map": "participation[typeCode=PRF]" } ] }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "short": "O resultado do exame em si", "definition": "O resultado do exame em si", "comment": "An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section](observation.html#notes) below.", "requirements": "9. SHALL contain exactly one [1..1] value with @xsi:type=\"PQ\" (CONF:7305).", "min": 1, "max": "1", "base": { "path": "Observation.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "boolean" }, { "code": "integer" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1", "obs-7", "vs-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "< 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "Observation.dataAbsentReason", "path": "Observation.dataAbsentReason", "short": "Por que o resultado não está disponível", "definition": "Por que o resultado não está disponível", "comment": "Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be \"detected\", \"not detected\", \"inconclusive\", or \"specimen unsatisfactory\". \n\nThe alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code \"error\" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "1", "base": { "path": "Observation.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1", "obs-6", "vs-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "short": "Interpretação da observação", "definition": "Interpretação da observação. Por exemplo: valor alto, baixo, normal", "comment": "Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.", "requirements": "For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.", "alias": [ "Abnormal Flag" ], "min": 0, "max": "*", "base": { "path": "Observation.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "Observation.note", "path": "Observation.note", "short": "Comentários sobre a observação", "definition": "Comentários sobre a observação", "comment": "May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.", "requirements": "Need to be able to provide free text additional information.", "min": 0, "max": "*", "base": { "path": "Observation.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Act" }, { "identity": "v2", "map": "NTE.3 (partner NTE to OBX, or sometimes another (child?) OBX)" }, { "identity": "rim", "map": "subjectOf.observationEvent[code=\"annotation\"].value" } ] }, { "id": "Observation.bodySite", "path": "Observation.bodySite", "short": "Parte do corpo examinada", "definition": "Parte do corpo examinada", "comment": "Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. \n\nIf the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension[ bodySite](extension-bodysite.html).", "min": 0, "max": "1", "base": { "path": "Observation.bodySite", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BodySite" } ], "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSet": "http://hl7.org/fhir/ValueSet/body-site" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 123037004 |Body structure|" }, { "identity": "v2", "map": "OBX-20" }, { "identity": "rim", "map": "targetSiteCode" }, { "identity": "sct-attr", "map": "718497002 |Inherent location|" } ] }, { "id": "Observation.method", "path": "Observation.method", "short": "Método usado para examinar", "definition": "Método usado para examinar", "comment": "Only used if not implicit in code for Observation.code.", "requirements": "In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.", "min": 0, "max": "1", "base": { "path": "Observation.method", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationMethod" } ], "strength": "example", "description": "Methods for simple observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-methods" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "OBX-17" }, { "identity": "rim", "map": "methodCode" } ] }, { "id": "Observation.specimen", "path": "Observation.specimen", "short": "Amostra examinada na observação", "definition": "Amostra examinada na observação", "comment": "Should only be used if not implicit in code found in `Observation.code`. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).", "min": 0, "max": "1", "base": { "path": "Observation.specimen", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-specimen" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 123038009 |Specimen|" }, { "identity": "v2", "map": "SPM segment" }, { "identity": "rim", "map": "participation[typeCode=SPC].specimen" }, { "identity": "sct-attr", "map": "704319004 |Inherent in|" } ] }, { "id": "Observation.device", "path": "Observation.device", "short": "Dispositivo (de medida)", "definition": "Dispositivo (de medida)", "comment": "Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.", "min": 0, "max": "1", "base": { "path": "Observation.device", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/DeviceMetric" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "sct-concept", "map": "< 49062001 |Device|" }, { "identity": "v2", "map": "OBX-17 / PRT -10" }, { "identity": "rim", "map": "participation[typeCode=DEV]" }, { "identity": "sct-attr", "map": "424226004 |Using device|" } ] }, { "id": "Observation.referenceRange", "path": "Observation.referenceRange", "short": "Fornece um guia para interpretação", "definition": "Fornece um guia para interpretação", "comment": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "Knowing what values are considered \"normal\" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "obs-3", "severity": "error", "human": "Must have at least a low or a high or text", "expression": "low.exists() or high.exists() or text.exists()", "xpath": "(exists(f:low) or exists(f:high)or exists(f:text))", "source": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Observation.referenceRange.id", "path": "Observation.referenceRange.id", "representation": [ "xmlAttr" ], "short": "Identificador único para referenciação cruzada", "definition": "Identificador único para referenciação cruzada", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.referenceRange.extension", "path": "Observation.referenceRange.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensões adicionais que não fazem parte do modelo de dados básico", "definition": "Extensões adicionais que não fazem parte do modelo de dados básico", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.referenceRange.modifierExtension", "path": "Observation.referenceRange.modifierExtension", "short": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "comment": "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.", "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.referenceRange.low", "path": "Observation.referenceRange.low", "short": "Limite inferior do intervalo", "definition": "Limite inferior do intervalo de valores de referência", "comment": "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.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.low", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.low" } ] }, { "id": "Observation.referenceRange.high", "path": "Observation.referenceRange.high", "short": "Limite superior do intervalo", "definition": "Limite superior do intervalo de valores de referência", "comment": "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.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.high", "min": 0, "max": "1" }, "type": [ { "code": "Quantity", "profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ] } ], "condition": [ "ele-1", "obs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "qty-3", "severity": "error", "human": "If a code for the unit is present, the system SHALL also be present", "expression": "code.empty() or system.exists()", "xpath": "not(exists(f:code)) or exists(f:system)", "source": "http://hl7.org/fhir/StructureDefinition/Quantity" }, { "key": "sqty-1", "severity": "error", "human": "The comparator is not used on a SimpleQuantity", "expression": "comparator.empty()", "xpath": "not(exists(f:comparator))", "source": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" } ], "isModifier": false, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "SN (see also Range) or CQ" }, { "identity": "rim", "map": "PQ, IVL, MO, CO, depending on the values" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:IVL_PQ.high" } ] }, { "id": "Observation.referenceRange.type", "path": "Observation.referenceRange.type", "short": "Qualificador do valor de referência", "definition": "Qualificador do valor de referência", "comment": "This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.", "requirements": "Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeMeaning" } ], "strength": "preferred", "description": "Code for the meaning of a reference range.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-meaning" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.referenceRange.appliesTo", "path": "Observation.referenceRange.appliesTo", "short": "População do intervalo de referência", "definition": "População do intervalo de referência", "comment": "This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.", "requirements": "Need to be able to identify the target population for proper interpretation.", "min": 0, "max": "*", "base": { "path": "Observation.referenceRange.appliesTo", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationRangeType" } ], "strength": "example", "description": "Codes identifying the population the reference range applies to.", "valueSet": "http://hl7.org/fhir/ValueSet/referencerange-appliesto" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values| OR \r< 365860008 |General clinical state finding| \rOR \r< 250171008 |Clinical history or observation findings| OR \r< 415229000 |Racial group| OR \r< 365400002 |Finding of puberty stage| OR\r< 443938003 |Procedure carried out on subject|" }, { "identity": "v2", "map": "OBX-10" }, { "identity": "rim", "map": "interpretationCode" } ] }, { "id": "Observation.referenceRange.age", "path": "Observation.referenceRange.age", "short": "Faixa etária aplicável", "definition": "Faixa etária aplicável, se relevante", "comment": "The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.", "requirements": "Some analytes vary greatly over age.", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.age", "min": 0, "max": "1" }, "type": [ { "code": "Range" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "rng-2", "severity": "error", "human": "If present, low SHALL have a lower value than high", "expression": "low.empty() or high.empty() or (low <= high)", "xpath": "not(exists(f:low/f:value/@value)) or not(exists(f:high/f:value/@value)) or (number(f:low/f:value/@value) <= number(f:high/f:value/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Range" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "NR and also possibly SN (but see also quantity)" }, { "identity": "rim", "map": "IVL [lowClosed=\"true\" and highClosed=\"true\"]or URG" }, { "identity": "rim", "map": "outboundRelationship[typeCode=PRCN].targetObservationCriterion[code=\"age\"].value" } ] }, { "id": "Observation.referenceRange.text", "path": "Observation.referenceRange.text", "short": "Intervalo de referência em formato textual", "definition": "Intervalo de referência em formato textual", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "Observation.referenceRange.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "OBX-7" }, { "identity": "rim", "map": "value:ST" } ] }, { "id": "Observation.hasMember", "path": "Observation.hasMember", "short": "Recurso relacionado que pertence ao grupo da Observação", "definition": "Recurso relacionado que pertence ao grupo da Observação", "comment": "When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see [Notes](observation.html#obsgrouping) below. Note that a system may calculate results from [QuestionnaireResponse](questionnaireresponse.html) into a final score and represent the score as an Observation.", "min": 0, "max": "*", "base": { "path": "Observation.hasMember", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": "outBoundRelationship" } ] }, { "id": "Observation.derivedFrom", "path": "Observation.derivedFrom", "short": "Medições relacionadas a partir das quais a observação é feita", "definition": "Medições relacionadas a partir das quais a observação é feita", "comment": "All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see [Notes](observation.html#obsgrouping) below.", "min": 0, "max": "*", "base": { "path": "Observation.derivedFrom", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/ImagingStudy", "http://hl7.org/fhir/StructureDefinition/Media", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-vitalsigns", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "Relationships established by OBX-4 usage" }, { "identity": "rim", "map": ".targetObservation" } ] }, { "id": "Observation.component", "path": "Observation.component", "short": "Resultados do componente", "definition": "Resultados do componente", "comment": "For a discussion on the ways Observations can be assembled in groups together see [Notes](observation.html#notes) below.", "requirements": "Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.", "min": 0, "max": "*", "base": { "path": "Observation.component", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "vs-3", "severity": "error", "human": "If there is no a value a data absent reason must be present", "expression": "value.exists() or dataAbsentReason.exists()", "xpath": "f:*[starts-with(local-name(.), 'value')] or f:dataAbsentReason", "source": "http://hl7.org/fhir/StructureDefinition/vitalsigns" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "containment by OBX-4?" }, { "identity": "rim", "map": "outBoundRelationship[typeCode=COMP]" } ] }, { "id": "Observation.component.id", "path": "Observation.component.id", "representation": [ "xmlAttr" ], "short": "Identificador único para referenciação cruzada", "definition": "Identificador único para referenciação cruzada", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Observation.component.extension", "path": "Observation.component.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensões adicionais que não fazem parte do modelo de dados básico", "definition": "Extensões adicionais que não fazem parte do modelo de dados básico", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.modifierExtension", "path": "Observation.component.modifierExtension", "short": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "comment": "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.", "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](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Observation.component.code", "path": "Observation.component.code", "short": "Tipo de observação de componente", "definition": "Describes what was observed. Sometimes this is called the observation \"code\".", "comment": "*All* code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.", "requirements": "Knowing what kind of observation is being made is essential to understanding the observation.", "min": 1, "max": "1", "base": { "path": "Observation.component.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "VitalSigns" } ], "strength": "extensible", "description": "This identifies the vital sign result type.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-vitalsignresult" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.what[x]" }, { "identity": "sct-concept", "map": "< 363787002 |Observable entity| OR \r< 386053000 |Evaluation procedure|" }, { "identity": "v2", "map": "OBX-3" }, { "identity": "rim", "map": "code" } ] }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "short": "O valor do resultado em si", "definition": "Vital Sign Value recorded with UCUM.", "comment": "Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section](observation.html#notes) below.", "requirements": "9. SHALL contain exactly one [1..1] value with @xsi:type=\"PQ\" (CONF:7305).", "min": 0, "max": "1", "base": { "path": "Observation.component.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "Quantity" }, { "code": "CodeableConcept" }, { "code": "string" }, { "code": "boolean" }, { "code": "integer" }, { "code": "Range" }, { "code": "Ratio" }, { "code": "SampledData" }, { "code": "time" }, { "code": "dateTime" }, { "code": "Period" } ], "condition": [ "ele-1", "vs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "VitalSignsUnits" } ], "strength": "required", "description": "Common UCUM units for recording Vital Signs.", "valueSet": "http://hl7.org/fhir/ValueSet/ucum-vitals-common|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "sct-concept", "map": "363714003 |Interprets| < 441742003 |Evaluation finding|" }, { "identity": "v2", "map": "OBX.2, OBX.5, OBX.6" }, { "identity": "rim", "map": "value" }, { "identity": "sct-attr", "map": "363714003 |Interprets|" } ] }, { "id": "Observation.component.dataAbsentReason", "path": "Observation.component.dataAbsentReason", "short": "Por que o resultado do componente está faltando", "definition": "Por que o resultado do componente está faltando", "comment": "\"Null\" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be \"detected\", \"not detected\", \"inconclusive\", or \"test not done\". \n\nThe alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code \"error\" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.", "requirements": "For many results it is necessary to handle exceptional values in measurements.", "min": 0, "max": "1", "base": { "path": "Observation.component.dataAbsentReason", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1", "obs-6", "vs-3" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationValueAbsentReason" } ], "strength": "extensible", "description": "Codes specifying why the result (`Observation.value[x]`) is missing.", "valueSet": "http://hl7.org/fhir/ValueSet/data-absent-reason" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "value.nullFlavor" } ] }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "short": "Interpretação da observação", "definition": "Interpretação da observação. Por exemplo: valor elevado", "comment": "Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.", "requirements": "For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.", "alias": [ "Abnormal Flag" ], "min": 0, "max": "*", "base": { "path": "Observation.component.interpretation", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationInterpretation" } ], "strength": "extensible", "description": "Codes identifying interpretations of observations.", "valueSet": "http://hl7.org/fhir/ValueSet/observation-interpretation" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "sct-concept", "map": "< 260245000 |Findings values|" }, { "identity": "v2", "map": "OBX-8" }, { "identity": "rim", "map": "interpretationCode" }, { "identity": "sct-attr", "map": "363713009 |Has interpretation|" } ] }, { "id": "Observation.component.referenceRange", "path": "Observation.component.referenceRange", "short": "Valores de referência", "definition": "Valores de referência para auxiliar na interpretação do resultado", "comment": "Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.", "requirements": "Knowing what values are considered \"normal\" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.", "min": 0, "max": "*", "base": { "path": "Observation.component.referenceRange", "min": 0, "max": "*" }, "contentReference": "http://hl7.org/fhir/StructureDefinition/Observation#Observation.referenceRange", "mapping": [ { "identity": "v2", "map": "OBX.7" }, { "identity": "rim", "map": "outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]" } ] } ] }, "differential": { "element": [ { "id": "Observation.id", "path": "Observation.id", "short": "Identificador lógico deste artefato", "definition": "Identificador lógico deste artefato" }, { "id": "Observation.meta", "path": "Observation.meta", "short": "Metadados sobre o recurso", "definition": "Metadados sobre o recurso" }, { "id": "Observation.implicitRules", "path": "Observation.implicitRules", "short": "URI(s) sob as quais este recurso é conhecido", "definition": "Um ou mais códigos que servem para identificar o tipo de recurso" }, { "id": "Observation.language", "path": "Observation.language", "short": "Linguagem do recurso", "definition": "A linguagem humana natural do recurso" }, { "id": "Observation.text", "path": "Observation.text", "short": "Texto narrativo, 72 caracteres para resumo", "definition": "Um texto narrativo resumindo as informações do recurso" }, { "id": "Observation.contained", "path": "Observation.contained", "short": "Recursos contidos", "definition": "Recursos contidos no recurso" }, { "id": "Observation.extension", "path": "Observation.extension", "short": "Extensões adicionais", "definition": "Extensões adicionais que não fazem parte do modelo base" }, { "id": "Observation.modifierExtension", "path": "Observation.modifierExtension", "short": "Extensões adicionais que não podem ser ignoradas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas" }, { "id": "Observation.identifier", "path": "Observation.identifier", "short": "Identificadores externos para este recurso", "definition": "Identificadores externos para este recurso" }, { "id": "Observation.basedOn", "path": "Observation.basedOn", "short": "Referência ao pedido ou ao plano de tratamento que gerou este recurso", "definition": "Referência ao pedido ou ao plano de tratamento que gerou este recurso", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-careplan", "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationrequest", "http://hl7.org/fhir/StructureDefinition/NutritionOrder", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-servicerequest" ] } ] }, { "id": "Observation.partOf", "path": "Observation.partOf", "short": "Referência ao evento do qual este recurso faz parte", "definition": "Referência ao evento do qual este recurso faz parte", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationadministration", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationdispense", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-medicationstatement", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-procedure", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-immunization", "http://hl7.org/fhir/StructureDefinition/ImagingStudy" ] } ] }, { "id": "Observation.status", "path": "Observation.status", "short": "Status atual da observação", "definition": "active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken" }, { "id": "Observation.category", "path": "Observation.category", "short": "Categoria de alto nível da observação", "definition": "Categoria de alto nível da observação" }, { "id": "Observation.category:VSCat", "path": "Observation.category", "sliceName": "VSCat", "short": "Classificação do tipo de observação", "definition": "Classificação do tipo de observação" }, { "id": "Observation.category:VSCat.id", "path": "Observation.category.id", "short": "Identificador exclusivo para referência entre elementos", "definition": "Identificador exclusivo para referência entre elementos" }, { "id": "Observation.category:VSCat.extension", "path": "Observation.category.extension", "short": "Conteúdo adicional definido por implementações", "definition": "Conteúdo adicional definido por implementações" }, { "id": "Observation.category:VSCat.coding", "path": "Observation.category.coding", "short": "Código definido por uma terminologia", "definition": "Código definido por uma terminologia" }, { "id": "Observation.category:VSCat.coding.id", "path": "Observation.category.coding.id", "short": "Identificador exclusivo para referência entre elementos", "definition": "Identificador exclusivo para referência entre elementos" }, { "id": "Observation.category:VSCat.coding.extension", "path": "Observation.category.coding.extension", "short": "Conteúdo adicional definido por implementações", "definition": "Conteúdo adicional definido por implementações" }, { "id": "Observation.category:VSCat.coding.system", "path": "Observation.category.coding.system", "short": "Identidade do sistema de terminologia", "definition": "Identidade do sistema de terminologia" }, { "id": "Observation.category:VSCat.coding.version", "path": "Observation.category.coding.version", "short": "Versão do sistema, se relevante", "definition": "Versão do sistema, se relevante" }, { "id": "Observation.category:VSCat.coding.code", "path": "Observation.category.coding.code", "short": "Símbolo na sintaxe definida pelo sistema", "definition": "Símbolo na sintaxe definida pelo sistema" }, { "id": "Observation.category:VSCat.coding.display", "path": "Observation.category.coding.display", "short": "Representação definida pelo sistema", "definition": "Representação definida pelo sistema" }, { "id": "Observation.category:VSCat.coding.userSelected", "path": "Observation.category.coding.userSelected", "short": "Se a codificação foi escolhida diretamente pelo usuário", "definition": "Se a codificação foi escolhida diretamente pelo usuário" }, { "id": "Observation.category:VSCat.text", "path": "Observation.category.text", "short": "Representação em texto simples do conceito", "definition": "Representação em texto simples do conceito" }, { "id": "Observation.code", "path": "Observation.code", "short": "Códigos dos resultados de sinais vitais do C-CDA", "definition": "Códigos dos resultados de sinais vitais do C-CDA" }, { "id": "Observation.subject", "path": "Observation.subject", "short": "De quem ou do que trata a observação", "definition": "De quem ou do que trata a observação", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-patient" ] } ] }, { "id": "Observation.focus", "path": "Observation.focus", "short": "Sobre o que é a observação, quando não é sobre o subject do registro", "definition": "Sobre o que é a observação, quando não é sobre o subject do registro" }, { "id": "Observation.encounter", "path": "Observation.encounter", "short": "Atendimento no qual a observação foi feita", "definition": "Atendimento no qual a observação foi feita", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-encounter" ] } ] }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "short": "Tempo ou período de tempo clinicamente relevante para os sinais vitais", "definition": "Tempo ou período de tempo clinicamente relevante para os sinais vitais" }, { "id": "Observation.issued", "path": "Observation.issued", "short": "Data ou hora em que esta versão da observação ficou disponível", "definition": "Data ou hora em que esta versão da observação ficou disponível", "min": 1 }, { "id": "Observation.performer", "path": "Observation.performer", "short": "O responsável pela observação", "definition": "O responsável pela observação", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-practitioner", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-practitionerrole", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-organization", "http://hl7.org/fhir/StructureDefinition/CareTeam", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-patient", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-relatedperson" ] } ] }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "short": "O resultado do exame em si", "definition": "O resultado do exame em si", "min": 1 }, { "id": "Observation.dataAbsentReason", "path": "Observation.dataAbsentReason", "short": "Por que o resultado não está disponível", "definition": "Por que o resultado não está disponível" }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "short": "Interpretação da observação", "definition": "Interpretação da observação. Por exemplo: valor alto, baixo, normal" }, { "id": "Observation.note", "path": "Observation.note", "short": "Comentários sobre a observação", "definition": "Comentários sobre a observação" }, { "id": "Observation.bodySite", "path": "Observation.bodySite", "short": "Parte do corpo examinada", "definition": "Parte do corpo examinada" }, { "id": "Observation.method", "path": "Observation.method", "short": "Método usado para examinar", "definition": "Método usado para examinar" }, { "id": "Observation.specimen", "path": "Observation.specimen", "short": "Amostra examinada na observação", "definition": "Amostra examinada na observação", "type": [ { "code": "Reference", "targetProfile": [ "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-specimen" ] } ] }, { "id": "Observation.device", "path": "Observation.device", "short": "Dispositivo (de medida)", "definition": "Dispositivo (de medida)" }, { "id": "Observation.referenceRange", "path": "Observation.referenceRange", "short": "Fornece um guia para interpretação", "definition": "Fornece um guia para interpretação" }, { "id": "Observation.referenceRange.id", "path": "Observation.referenceRange.id", "short": "Identificador único para referenciação cruzada", "definition": "Identificador único para referenciação cruzada" }, { "id": "Observation.referenceRange.extension", "path": "Observation.referenceRange.extension", "short": "Extensões adicionais que não fazem parte do modelo de dados básico", "definition": "Extensões adicionais que não fazem parte do modelo de dados básico" }, { "id": "Observation.referenceRange.modifierExtension", "path": "Observation.referenceRange.modifierExtension", "short": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas" }, { "id": "Observation.referenceRange.low", "path": "Observation.referenceRange.low", "short": "Limite inferior do intervalo", "definition": "Limite inferior do intervalo de valores de referência" }, { "id": "Observation.referenceRange.high", "path": "Observation.referenceRange.high", "short": "Limite superior do intervalo", "definition": "Limite superior do intervalo de valores de referência" }, { "id": "Observation.referenceRange.type", "path": "Observation.referenceRange.type", "short": "Qualificador do valor de referência", "definition": "Qualificador do valor de referência" }, { "id": "Observation.referenceRange.appliesTo", "path": "Observation.referenceRange.appliesTo", "short": "População do intervalo de referência", "definition": "População do intervalo de referência" }, { "id": "Observation.referenceRange.age", "path": "Observation.referenceRange.age", "short": "Faixa etária aplicável", "definition": "Faixa etária aplicável, se relevante" }, { "id": "Observation.referenceRange.text", "path": "Observation.referenceRange.text", "short": "Intervalo de referência em formato textual", "definition": "Intervalo de referência em formato textual" }, { "id": "Observation.hasMember", "path": "Observation.hasMember", "short": "Recurso relacionado que pertence ao grupo da Observação", "definition": "Recurso relacionado que pertence ao grupo da Observação", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ] }, { "id": "Observation.derivedFrom", "path": "Observation.derivedFrom", "short": "Medições relacionadas a partir das quais a observação é feita", "definition": "Medições relacionadas a partir das quais a observação é feita", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/ImagingStudy", "http://hl7.org/fhir/StructureDefinition/Media", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "https://br-core.saude.gov.br/fhir/StructureDefinition/br-core-vitalsigns", "http://hl7.org/fhir/StructureDefinition/MolecularSequence" ] } ] }, { "id": "Observation.component", "path": "Observation.component", "short": "Resultados do componente", "definition": "Resultados do componente" }, { "id": "Observation.component.id", "path": "Observation.component.id", "short": "Identificador único para referenciação cruzada", "definition": "Identificador único para referenciação cruzada" }, { "id": "Observation.component.extension", "path": "Observation.component.extension", "short": "Extensões adicionais que não fazem parte do modelo de dados básico", "definition": "Extensões adicionais que não fazem parte do modelo de dados básico" }, { "id": "Observation.component.modifierExtension", "path": "Observation.component.modifierExtension", "short": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas", "definition": "Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas" }, { "id": "Observation.component.code", "path": "Observation.component.code", "short": "Tipo de observação de componente" }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "short": "O valor do resultado em si" }, { "id": "Observation.component.dataAbsentReason", "path": "Observation.component.dataAbsentReason", "short": "Por que o resultado do componente está faltando", "definition": "Por que o resultado do componente está faltando" }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "short": "Interpretação da observação", "definition": "Interpretação da observação. Por exemplo: valor elevado" }, { "id": "Observation.component.referenceRange", "path": "Observation.component.referenceRange", "short": "Valores de referência", "definition": "Valores de referência para auxiliar na interpretação do resultado" } ] } }