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

: Exemplo de procedimento de saúde. - XML Representation

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<Procedure xmlns="http://hl7.org/fhir">
  <id value="b0030c23-bd7d-445e-bfe5-020828f7dbaf"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Procedure b0030c23-bd7d-445e-bfe5-020828f7dbaf</b></p><a name="b0030c23-bd7d-445e-bfe5-020828f7dbaf"> </a><a name="hcb0030c23-bd7d-445e-bfe5-020828f7dbaf"> </a><a name="b0030c23-bd7d-445e-bfe5-020828f7dbaf-pt-BR"> </a><p><b>identifier</b>: <code>https://saude.gov.br/fhir/sid/procedure</code>/PROC-12345</p><p><b>status</b>: Completed</p><p><b>statusReason</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/ValueSet/BRMotivoProcedimentoNaoRealizado 03}">Procedimento não realizado</span></p><p><b>category</b>: <span title="Codes:{https://fhir.ans.gov.br/CodeSystem/tuss-50 04}">Consulta</span></p><p><b>code</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRTabelaSUS 0301010064}">Consulta médica em atenção primária</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>performed</b>: 2023-12-12 09:00:00-0300 --&gt; 2023-12-12 10:30:00-0300</p><h3>Performers</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Function</b></td><td><b>Actor</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/participant-type emergency}">Emergência</span></td><td><a href="Practitioner-d3b61455-f432-48f0-b83b-ba825922d735.html">Maria Clara</a></td></tr></table><p><b>reasonCode</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10 I10}">Hipertensão essencial (primária)</span></p><p><b>bodySite</b>: <span title="Codes:{http://snomed.info/sct 480000}">Sistema Circulatório</span></p><p><b>outcome</b>: <span title="Codes:{https://terminologia.saude.gov.br/fhir/CodeSystem/BRDesfechoProcedimento 01}">Melhora Clínica</span></p><p><b>report</b>: <a href="DiagnosticReport/example-report">Relatório consulta</a></p><p><b>complicationDetail</b>: <a href="Condition-91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5.html">Dispnéia</a></p><p><b>followUp</b>: <span title="Codes:">Consulta de acompanhamento em 2 semanas</span></p><p><b>note</b>: O paciente foi orientado a fazer atividade física.</p></div>
  </text>
  <identifier>
    <system value="https://saude.gov.br/fhir/sid/procedure"/>
    <value value="PROC-12345"/>
  </identifier>
  <status value="completed"/>
  <statusReason>
    <coding>
      <system
              value="https://terminologia.saude.gov.br/fhir/ValueSet/BRMotivoProcedimentoNaoRealizado"/>
      <code value="03"/>
      <display value="Procedimento não realizado"/>
    </coding>
  </statusReason>
  <category>
    <coding>
      <system value="https://fhir.ans.gov.br/CodeSystem/tuss-50"/>
      <code value="04"/>
      <display value="Consulta"/>
    </coding>
    <text value="Consulta"/>
  </category>
  <code>
    <coding>
      <system
              value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRTabelaSUS"/>
      <code value="0301010064"/>
      <display value="CONSULTA MÉDICA EM ATENÇÃO PRIMÁRIA"/>
    </coding>
    <text value="Consulta médica em atenção primária"/>
  </code>
  <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>
  <performedPeriod>
    <start value="2023-12-12T09:00:00-03:00"/>
    <end value="2023-12-12T10:30:00-03:00"/>
  </performedPeriod>
  <performer>
    <function>
      <coding>
        <system
                value="http://terminology.hl7.org/CodeSystem/participant-type"/>
        <code value="emergency"/>
        <display value="Emergency"/>
      </coding>
      <text value="Emergência"/>
    </function>
    <actor>🔗 
      <reference value="Practitioner/d3b61455-f432-48f0-b83b-ba825922d735"/>
      <display value="Maria Clara"/>
    </actor>
  </performer>
  <reasonCode>
    <coding>
      <system
              value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRCID10"/>
      <code value="I10"/>
      <display value="Hipertensão essencial (primária)"/>
    </coding>
    <text value="Hipertensão essencial (primária)"/>
  </reasonCode>
  <bodySite>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="480000"/>
      <display value="Cardiopulmonary circulatory system"/>
    </coding>
    <text value="Sistema Circulatório"/>
  </bodySite>
  <outcome>
    <coding>
      <system
              value="https://terminologia.saude.gov.br/fhir/CodeSystem/BRDesfechoProcedimento"/>
      <code value="01"/>
      <display value="Melhora Clínica"/>
    </coding>
    <text value="Melhora Clínica"/>
  </outcome>
  <report>
    <reference value="DiagnosticReport/example-report"/>
    <display value="Relatório consulta"/>
  </report>
  <complicationDetail>🔗 
    <reference value="Condition/91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5"/>
    <display value="Dispnéia"/>
  </complicationDetail>
  <followUp>
    <text value="Consulta de acompanhamento em 2 semanas"/>
  </followUp>
  <note>
    <text value="O paciente foi orientado a fazer atividade física."/>
  </note>
</Procedure>