Guia de implementação do Core do Brasil: Release 1 - BR Realm | STU1
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This page is part of the Core do Brasil (v1.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Registro de Atendimento Clínico - XML Representation

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<Composition xmlns="http://hl7.org/fhir">
  <id value="7681618d-399d-4291-b321-32ce6d645088"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Composition 7681618d-399d-4291-b321-32ce6d645088</b></p><a name="7681618d-399d-4291-b321-32ce6d645088"> </a><a name="hc7681618d-399d-4291-b321-32ce6d645088"> </a><a name="7681618d-399d-4291-b321-32ce6d645088-pt-BR"> </a><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 11488-4}">Nota de consulta</span></p><p><b>category</b>: <span title="Codes:{http://loinc.org 11488-4}">Nota de consulta</span></p><p><b>encounter</b>: <a href="Encounter-c6d553d8-cce0-404b-9d1f-eeffbf7fc6df.html">Ambulatorial</a></p><p><b>date</b>: 2024-12-19 14:30:00+0000</p><p><b>author</b>: <a href="Practitioner-d3b61455-f432-48f0-b83b-ba825922d735.html">Maria Clara</a></p><p><b>title</b>: Registro de Atendimento Clínico</p></div>
  </text>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11488-4"/>
      <display value="Consult note"/>
    </coding>
    <text value="Nota de consulta"/>
  </type>
  <category>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11488-4"/>
      <display value="Consult note"/>
    </coding>
    <text value="Nota de consulta"/>
  </category>
  <subject>🔗 
    <reference value="Patient/b2f63a4c-ddaa-4652-8481-ac1ff473104e"/>
    <display value="João Carlos Silva"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/c6d553d8-cce0-404b-9d1f-eeffbf7fc6df"/>
    <display value="Ambulatorial"/>
  </encounter>
  <date value="2024-12-19T14:30:00Z"/>
  <author>🔗 
    <reference value="Practitioner/d3b61455-f432-48f0-b83b-ba825922d735"/>
    <display value="Maria Clara"/>
  </author>
  <title value="Registro de Atendimento Clínico"/>
  <section>
    <title value="Diagnósticos Avaliados"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="57852-6"/>
        <display value="Problem list Reported"/>
      </coding>
      <text value="Lista de Problemas - Diagnósticos Avaliados"/>
    </code>
    <entry>🔗 
      <reference value="Condition/91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5"/>
      <display value="Dispnéia"/>
    </entry>
  </section>
  <section>
    <title value="Procedimentos Realizados"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="47519-4"/>
        <display value="Procedures Hx Doc"/>
      </coding>
      <text value="Procedimentos Realizados"/>
    </code>
    <entry>🔗 
      <reference value="Procedure/b0030c23-bd7d-445e-bfe5-020828f7dbaf"/>
      <display value="Consulta médica em atenção primária"/>
    </entry>
  </section>
  <section>
    <title value="Sinais Vitais"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="85354-9"/>
        <display value="Blood pressure panel with all children optional"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Observation/07ce5462-f77b-4ad6-af8c-2f67a6500b97"/>
      <display value="Vital Signs"/>
    </entry>
  </section>
  <section>
    <title value="Alergias e Intolerâncias"/>
    <code>
      <coding>
        <system
                value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRAlergenosCBARA"/>
        <code value="A100"/>
        <display value="Amendoim"/>
      </coding>
    </code>
    <entry>🔗 
      <reference
                 value="AllergyIntolerance/42a8e4ee-cc8b-4c07-bee2-da8fe14ada34"/>
      <display value="Allergy Intolerance"/>
    </entry>
  </section>
  <section>
    <title value="Medicamentos"/>
    <code>
      <coding>
        <system value="http://www.whocc.no/atc"/>
        <code value="J01MA12"/>
        <display value="levofloxacin"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="Medication/3a46210c-7eb3-48ec-aa67-db7e7ee18864"/>
      <display value="Medication"/>
    </entry>
  </section>
  <section>
    <title value="Plano de Cuidados"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Plan of care note"/>
      </coding>
    </code>
    <entry>🔗 
      <reference value="CarePlan/1ed343f2-5231-40d6-a6ea-4428105b7532"/>
      <display value="CarePlan"/>
    </entry>
  </section>
</Composition>