Guia de implementação do Core do Brasil: Release 1 - BR Realm | STU1
1.0.0 - STU1
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
<Condition xmlns="http://hl7.org/fhir">
<id value="91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Condition 91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5</b></p><a name="91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5"> </a><a name="hc91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5"> </a><a name="91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5-pt-BR"> </a><p><b>identifier</b>: <code>http://hospital.org/conditions</code>/12345</p><p><b>clinicalStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}">Active</span></p><p><b>verificationStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-ver-status confirmed}">Confirmed</span></p><p><b>category</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRCategoriaDiagnostico 01}">Principal</span></p><p><b>severity</b>: <span title="Codes:{http://snomed.info/sct 6736007}">Moderate (severity modifier) (qualifier value)</span></p><p><b>code</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10 I15.9}">Hipertensão secundária, não especificada</span></p><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 80891009}">Coração</span></p><p><b>subject</b>: <a href="Patient-b2f63a4c-ddaa-4652-8481-ac1ff473104e.html">João Carlos Silva</a></p><p><b>encounter</b>: <a href="Encounter-c6d553d8-cce0-404b-9d1f-eeffbf7fc6df.html">Ambulatorial</a></p><p><b>onset</b>: 2024-03-28</p><p><b>recordedDate</b>: 2024-04-05 10:00:00+0000</p><p><b>recorder</b>: <a href="Practitioner-d3b61455-f432-48f0-b83b-ba825922d735.html">Maria Clara</a></p><p><b>asserter</b>: <a href="Practitioner-d3b61455-f432-48f0-b83b-ba825922d735.html">Maria Clara</a></p><h3>Evidences</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Detail</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10 R50.9}, {https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10 R05}">Febre não especificada</span></td><td><a href="Observation-07ce5462-f77b-4ad6-af8c-2f67a6500b97.html">Vital Signs</a></td></tr></table><p><b>note</b>: Paciente apresentou melhora significativa após início do tratamento com antibióticos.</p></div>
</text>
<identifier>
<system value="http://hospital.org/conditions"/>
<value value="12345"/>
</identifier>
<clinicalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
<display value="Active"/>
</coding>
</clinicalStatus>
<verificationStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
<code value="confirmed"/>
<display value="Confirmed"/>
</coding>
</verificationStatus>
<category>
<coding>
<system
value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRCategoriaDiagnostico"/>
<code value="01"/>
<display value="Principal"/>
</coding>
</category>
<severity>
<coding>
<system value="http://snomed.info/sct"/>
<code value="6736007"/>
<display value="Moderate (severity modifier) (qualifier value)"/>
</coding>
</severity>
<code>
<coding>
<system
value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10"/>
<code value="I15.9"/>
<display value="Hipertensão secundária, não especificada"/>
</coding>
</code>
<bodySite>
<coding>
<system value="http://snomed.info/sct"/>
<code value="80891009"/>
<display value="Heart structure (body structure)"/>
</coding>
<text value="Coração"/>
</bodySite>
<subject>🔗
<reference value="Patient/b2f63a4c-ddaa-4652-8481-ac1ff473104e"/>
<type value="Patient"/>
<display value="João Carlos Silva"/>
</subject>
<encounter>🔗
<reference value="Encounter/c6d553d8-cce0-404b-9d1f-eeffbf7fc6df"/>
<display value="Ambulatorial"/>
</encounter>
<onsetDateTime value="2024-03-28"/>
<recordedDate value="2024-04-05T10:00:00Z"/>
<recorder>🔗
<reference value="Practitioner/d3b61455-f432-48f0-b83b-ba825922d735"/>
<display value="Maria Clara"/>
</recorder>
<asserter>🔗
<reference value="Practitioner/d3b61455-f432-48f0-b83b-ba825922d735"/>
<display value="Maria Clara"/>
</asserter>
<evidence>
<code>
<coding>
<system
value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10"/>
<code value="R50.9"/>
<display value="Febre não especificada"/>
</coding>
<coding>
<system
value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10"/>
<code value="R05"/>
<display value="Tosse"/>
</coding>
</code>
<detail>🔗
<reference value="Observation/07ce5462-f77b-4ad6-af8c-2f67a6500b97"/>
<display value="Vital Signs"/>
</detail>
</evidence>
<note>
<text
value="Paciente apresentou melhora significativa após início do tratamento com antibióticos."/>
</note>
</Condition>