Identificador do sistema de terminologia

Versão do sistema de terminologia, se relevante

Símbolo na sintaxe definida pelo sistema

Representação definida pelo sistema

Se este código foi escolhido diretamente pelo usuário

Representação em texto livre do conceito

O status de verificação para apoiar ou recusar o status clínico da condição ou do diagnóstico

Achado funcional (capacidade ou incapacidade). Preferencialmente SNOMED CT (Functional finding); CID-10 ou CIAP-2 da condição de base podem vir como codificação adicional

Indivíduo com a Condição de Saúde avaliada

Identificador único para referência cruzada

Extensões adicionais definidas pela implementação

Descrição do identificador

O namespace do valor do identificador

Valor único do identificador

Período de tempo no qual este identicador é/ou foi válido para utilização

Organização que emitiu o documento de identificação (pode ser apenas texto)

Data na qual o registro foi registrado pela primeira vez

Referência à avaliação que sustenta o grau de capacidade funcional: escala aplicada, observação ou laudo

Referência à informações de apoio

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Um conjunto de regras sob as quais este conteúdo foi criado

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.

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

O status clínico da condição ou do diagnóstico

The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

The clinical status of the condition or diagnosis.

A reference to a code defined by a terminology system.

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.

Allows for alternative encodings within a code system, and translations to other code systems.

Identificador do sistema de terminologia

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.

Need to be unambiguous about the source of the definition of the symbol.

Versão do sistema de terminologia, se relevante

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.

Símbolo na sintaxe definida pelo sistema

Need to refer to a particular code in the system.

Representação definida pelo sistema

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Se este código foi escolhido diretamente pelo usuário

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.

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.

Representação em texto livre do conceito

Very often the text is the same as a displayName of one of the codings.

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.

O status de verificação para apoiar ou recusar o status clínico da condição ou do diagnóstico

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

The verification status to support or decline the clinical status of the condition or diagnosis.

Categoria da condição

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Achado funcional (capacidade ou incapacidade). Preferencialmente SNOMED CT (Functional finding); CID-10 ou CIAP-2 da condição de base podem vir como codificação adicional

0..1 to account for primarily narrative only resources.

Indivíduo com a Condição de Saúde avaliada

Group is typically used for veterinary or public health use cases.

Data na qual o registro foi registrado pela primeira vez

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Um conjunto de regras sob as quais este conteúdo foi criado

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.

Idioma do recurso

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).

A human language.

Resumo do texto do recurso em linguagem natural

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.

Recursos contidos no recurso

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.

Extensões adicionais que não fazem parte do modelo base

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

O status clínico da condição ou do diagnóstico

The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

The clinical status of the condition or diagnosis.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

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.

A reference to a code defined by a terminology system.

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.

Allows for alternative encodings within a code system, and translations to other code systems.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

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.

Identificador do sistema de terminologia

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.

Need to be unambiguous about the source of the definition of the symbol.

Versão do sistema de terminologia, se relevante

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.

Símbolo na sintaxe definida pelo sistema

Need to refer to a particular code in the system.

Representação definida pelo sistema

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Se este código foi escolhido diretamente pelo usuário

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.

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.

Representação em texto livre do conceito

Very often the text is the same as a displayName of one of the codings.

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.

O status de verificação para apoiar ou recusar o status clínico da condição ou do diagnóstico

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

The verification status to support or decline the clinical status of the condition or diagnosis.

Categoria da condição

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Severidade da condição

Coding of the severity with a terminology is preferred, where possible.

A subjective assessment of the severity of the condition as evaluated by the clinician.

Achado funcional (capacidade ou incapacidade). Preferencialmente SNOMED CT (Functional finding); CID-10 ou CIAP-2 da condição de base podem vir como codificação adicional

0..1 to account for primarily narrative only resources.

Local anatômico da condição, se relevante

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.

Indivíduo com a Condição de Saúde avaliada

Group is typically used for veterinary or public health use cases.

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Referência literal. URL relativa, interna ou externa

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Tipo de recurso ao qual a referência é feita

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

Referência lógica, quando a referência literal não é conhecida

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Identificador único para referência cruzada

Extensões adicionais definidas pela implementação

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Descrição do identificador

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

O namespace do valor do identificador

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Valor único do identificador

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Período de tempo no qual este identicador é/ou foi válido para utilização

Organização que emitiu o documento de identificação (pode ser apenas texto)

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Texto alternativo para o recurso

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Referência ao atendimento no qual a condição foi diagnosticada

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Data ou idade estimada ou real do começo dos sintomas

Age is generally used when the patient reports an age at which the Condition began to occur.

Data ou idade estimada ou real em que o diagnóstico foi resolvido ou entrou em remissão

There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

Data na qual o registro foi registrado pela primeira vez

Quem registrou a condição

Pessoa que afirma a condição

Estágio/grau da condição, geralmente avaliado formalmente

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Códigos descrevendo estágios da condição (por exemplo, estágios de câncer)

Codes describing condition stages (e.g. Cancer stages).

Referência à avaliação que sustenta o grau de capacidade funcional: escala aplicada, observação ou laudo

Códigos que descrevem o tipo do estadiamento (por exemplo, clínico ou patológico)

Codes describing the kind of condition staging (e.g. clinical or pathological).

Evidências de apoio ao diagnóstico

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Códigos que descrevem a manifestação ou sintomas de uma condição

Codes that describe the manifestation or symptoms of a condition.

Referência à informações de apoio

Informações adicionais sobre a condição