Escopo/Uso

Este perfil define expectativas mínimas para o recurso Observation registrar, pesquisar e buscar dados sobre o consumo de álcool associados a um paciente. Ele especifica quais elementos principais, extensões, vocabulários e conjuntos de valores DEVEM estar presentes no recurso e restringe como os elementos são usados. Fornece a base para o desenvolvimento de padrões para casos de uso específicos promove a interoperabilidade e a adoção do recurso.

Uso indevido

O perfil br-core-observationalcohooluse é projetado para documentar o uso de álcool na história social de um paciente, e seu uso deve ser adequado ao contexto clínico específico e não deve ser utilizado para registrar outros comportamentos de saúde.

Caso de uso

Este perfil pode ser usado em diferentes contextos clínicos para garantir a interoperabilidade e a consistência na documentação do uso. Exemplos de caso de uso:

• Consulta de Avaliação de Saúde:
• Documentar o uso de álcool durante uma consulta de avaliação geral de saúde.
• Monitoramento de Pacientes Crônicos:
• Avaliar o impacto do uso de álcool em pacientes com condições crônicas.
• Programas de Cessação de Álcool:
• Registrar a história de uso de álcool e acompanhar o progresso do paciente em programas de cessação.

MUST SUPPORT - Elementos de dados obrigatórios e que devem estar presentes

1. status: status da observação
2. code: Identifica o tipo de observação. No caso do uso de álcool, é comum utilizar um código LOINC apropriado, como 74013-4 para “Uso de álcool”.
3. subject: Referência ao paciente (indivíduo) para o qual a observação está sendo registrada.
4. effective[x]: O período ou data efetiva em que a observação foi feita.
5. Data-absent-reason: must support quando a informação sobre uso de álcool não estiverem presentes no registro do Sumário do Paciente

Extensões

O perfil pode incluir extensões para adicionar informações adicionais, como a razão da ausência de dados (data-absent-reason).

Limites e relacionamentos

Este perfil pode ser usado em conjunto com outros perfis FHIR, como o br-core-registroatendimentoclinico e o br-core-composition, para integrar informações de uso de álcool em resumos de pacientes.

• Tabela diferencial
• Tabela de elementos -chave
• Tabela de instantâneos
• Estatísticas/Referências
• Todos

Esta estrutura é derivada de BRCoreObservation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	BRCoreObservation	Measurements and simple assertions
code
coding		0..*	Coding	Código definido por uma terminologia
system		0..1	uri	Identificador da terminologia Required Pattern: http://loinc.org
code		0..1	code	Código do conceito na sintaxe definida pela terminologia Fixed Value: 74013-4
display		0..1	string	Descrição conforme definido pela terminologia Required Pattern: Alcoholic drinks per D
text		0..1	string	Plain text representation of the concept Required Pattern: Número de doses de álcool ingeridos por dia
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	BRCoreObservation	Measurements and simple assertions dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
implicitRules	?!Σ	0..1	uri	Um conjunto de regras sob as quais este conteúdo foi criado ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensões que não podem ser ignoradas ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	Status atual da observação Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
category		1..1	CodeableConcept	Categoria de alto nível da observação Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Código da observação Binding: LOINCCodes (example): Codes identifying names of simple observations. ele-1: All FHIR elements must have a @value or children
coding	Σ	0..*	Coding	Código definido por uma terminologia ele-1: All FHIR elements must have a @value or children
system	Σ	0..1	uri	Identificador da terminologia ele-1: All FHIR elements must have a @value or children Required Pattern: http://loinc.org
code	Σ	0..1	code	Código do conceito na sintaxe definida pela terminologia ele-1: All FHIR elements must have a @value or children Fixed Value: 74013-4
display	Σ	0..1	string	Descrição conforme definido pela terminologia ele-1: All FHIR elements must have a @value or children Required Pattern: Alcoholic drinks per D
text	Σ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children Required Pattern: Número de doses de álcool ingeridos por dia
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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 : 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()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	BRCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
id	Σ	0..1	id	ID do artefato
meta	Σ	0..1	Meta	Metadados sobre recurso
implicitRules	?!Σ	0..1	uri	Um conjunto de regras sob as quais este conteúdo foi criado
language		0..1	code	Idioma do conteúdo do recurso Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Texto com o resumo do recurso
contained		0..*	Resource	Recursos contidos
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensões que não podem ser ignoradas
identifier	Σ	0..*	Identifier	Identificador do Observation
basedOn	Σ	0..*	Reference(BRCoreCarePlan | DeviceRequest | ImmunizationRecommendation | br-core-medicationrequest | NutritionOrder | BRCoreServiceRequest)	Referência ao pedido ou ao plano de tratamento que gerou este recurso
partOf	Σ	0..*	Reference(br-core-medicationadministration | br-core-medicationdispense | br-core-medicationstatement | BRCoreProcedure | BRCoreImmunization | ImagingStudy)	Referência ao evento do qual este recurso faz parte
status	?!Σ	1..1	code	Status atual da observação Binding: ObservationStatus (required): Codes providing the status of an observation.
category		1..1	CodeableConcept	Categoria de alto nível da observação Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Código da observação Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Código definido por uma terminologia
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identificador da terminologia Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Código do conceito na sintaxe definida pela terminologia Fixed Value: 74013-4
display	Σ	0..1	string	Descrição conforme definido pela terminologia Required Pattern: Alcoholic drinks per D
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept Required Pattern: Número de doses de álcool ingeridos por dia
subject	Σ	0..1	Reference(BRCorePatient | br-core-location | Device | Group)	De quem ou do que trata a observação
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referência literal, URL relativa, interna ou absoluta
type	Σ	0..1	uri	Tipo de referência (por exemplo, Paciente) Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Referência lógica, quando a referência literal não é conhecida
display	Σ	0..1	string	Texto alternativo para este rescurso
focus	Σ	0..*	Reference(Resource)	Sobre o que é a observação, quando esta não é sobre o sujeito do registro
encounter	Σ	0..1	Reference(br-core-encounter)	Atendimento durante o qual esta observação foi registrada
effective[x]	Σ	0..1		Tempo ou período de tempo clinicamente relevante para a observação
effective[x]All Types				Content/Rules for all Types
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
extension:All Slices				Content/Rules for all slices
id		0..1	string	Identificador único para referenciação cruzada
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
url		1..1	uri	Por quê o valor esperado não está presente
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Data/hora em que esta versão foi disponibilizada
performer	Σ	0..*	Reference(BRCorePractitioner | BRCorePractitionerRole | BRCoreOrganization | CareTeam | BRCorePatient | BRCoreRelatedPerson)	Quem é o responsável pela observação
value[x]	ΣC	0..1		Resultado da observação
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Por quê o resultado está faltando Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	Interpretação do resultado Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comentários sobre a observação
bodySite		0..1	CodeableConcept	Parte anatômica alvo da observação Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	Método de medição Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(BRCoreSpecimen)	Amostra utilizada para esta observação
device		0..1	Reference(Device | DeviceMetric)	Dispositivo de medida da observação
referenceRange	C	0..*	BackboneElement	Fornece um guia para interpretação obs-3: Must have at least a low or a high or text
id		0..1	string	Identificador único para referenciação cruzada
extension		0..*	Extension	Extensões adicionais que não fazem parte do modelo de dados básico
modifierExtension	?!Σ	1..1	Extension	Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas
low	C	0..1	SimpleQuantity	Limite inferior do intervalo
high	C	0..1	SimpleQuantity	Limite superior do intervalo
type		0..1	CodeableConcept	Qualificador do valor de referência Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	População do intervalo de referência Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Faixa etária aplicável
text		1..1	string	Intervalo de referência em formato textual
hasMember	Σ	0..*	Reference(BRCoreObservation | QuestionnaireResponse | MolecularSequence)	Recurso relacionado que pertence a observação
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | BRCoreObservation | MolecularSequence)	Medições relacionadas a partir das quais a observação é feita
component	Σ	0..*	BackboneElement	Resultados do componente
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações
modifierExtension	?!Σ	0..*	Extension	Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas
code	Σ	1..1	CodeableConcept	Tipo do componente da observação Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Resultado do componente
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Por que o resultado do componente está ausente Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	Interpretação do resultado do componente Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Valores de referência
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Observation.method	example	ObservationMethods http://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard
Observation.component.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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 : 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()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Visão diferencial

Esta estrutura é derivada de BRCoreObservation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	BRCoreObservation	Measurements and simple assertions
code
coding		0..*	Coding	Código definido por uma terminologia
system		0..1	uri	Identificador da terminologia Required Pattern: http://loinc.org
code		0..1	code	Código do conceito na sintaxe definida pela terminologia Fixed Value: 74013-4
display		0..1	string	Descrição conforme definido pela terminologia Required Pattern: Alcoholic drinks per D
text		0..1	string	Plain text representation of the concept Required Pattern: Número de doses de álcool ingeridos por dia
Documentation for this format

Visualização de elementos -chave

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	BRCoreObservation	Measurements and simple assertions dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
implicitRules	?!Σ	0..1	uri	Um conjunto de regras sob as quais este conteúdo foi criado ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensões que não podem ser ignoradas ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	Status atual da observação Binding: ObservationStatus (required): Codes providing the status of an observation. ele-1: All FHIR elements must have a @value or children
category		1..1	CodeableConcept	Categoria de alto nível da observação Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Código da observação Binding: LOINCCodes (example): Codes identifying names of simple observations. ele-1: All FHIR elements must have a @value or children
coding	Σ	0..*	Coding	Código definido por uma terminologia ele-1: All FHIR elements must have a @value or children
system	Σ	0..1	uri	Identificador da terminologia ele-1: All FHIR elements must have a @value or children Required Pattern: http://loinc.org
code	Σ	0..1	code	Código do conceito na sintaxe definida pela terminologia ele-1: All FHIR elements must have a @value or children Fixed Value: 74013-4
display	Σ	0..1	string	Descrição conforme definido pela terminologia ele-1: All FHIR elements must have a @value or children Required Pattern: Alcoholic drinks per D
text	Σ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children Required Pattern: Número de doses de álcool ingeridos por dia
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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 : 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()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Visualização instantânea

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	BRCoreObservation	Measurements and simple assertions obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
id	Σ	0..1	id	ID do artefato
meta	Σ	0..1	Meta	Metadados sobre recurso
implicitRules	?!Σ	0..1	uri	Um conjunto de regras sob as quais este conteúdo foi criado
language		0..1	code	Idioma do conteúdo do recurso Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Texto com o resumo do recurso
contained		0..*	Resource	Recursos contidos
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensões que não podem ser ignoradas
identifier	Σ	0..*	Identifier	Identificador do Observation
basedOn	Σ	0..*	Reference(BRCoreCarePlan | DeviceRequest | ImmunizationRecommendation | br-core-medicationrequest | NutritionOrder | BRCoreServiceRequest)	Referência ao pedido ou ao plano de tratamento que gerou este recurso
partOf	Σ	0..*	Reference(br-core-medicationadministration | br-core-medicationdispense | br-core-medicationstatement | BRCoreProcedure | BRCoreImmunization | ImagingStudy)	Referência ao evento do qual este recurso faz parte
status	?!Σ	1..1	code	Status atual da observação Binding: ObservationStatus (required): Codes providing the status of an observation.
category		1..1	CodeableConcept	Categoria de alto nível da observação Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Código da observação Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Código definido por uma terminologia
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identificador da terminologia Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Código do conceito na sintaxe definida pela terminologia Fixed Value: 74013-4
display	Σ	0..1	string	Descrição conforme definido pela terminologia Required Pattern: Alcoholic drinks per D
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept Required Pattern: Número de doses de álcool ingeridos por dia
subject	Σ	0..1	Reference(BRCorePatient | br-core-location | Device | Group)	De quem ou do que trata a observação
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referência literal, URL relativa, interna ou absoluta
type	Σ	0..1	uri	Tipo de referência (por exemplo, Paciente) Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Referência lógica, quando a referência literal não é conhecida
display	Σ	0..1	string	Texto alternativo para este rescurso
focus	Σ	0..*	Reference(Resource)	Sobre o que é a observação, quando esta não é sobre o sujeito do registro
encounter	Σ	0..1	Reference(br-core-encounter)	Atendimento durante o qual esta observação foi registrada
effective[x]	Σ	0..1		Tempo ou período de tempo clinicamente relevante para a observação
effective[x]All Types				Content/Rules for all Types
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
extension:All Slices				Content/Rules for all slices
id		0..1	string	Identificador único para referenciação cruzada
extension		0..*	Extension	Conteúdo adicional definido por implementações Slice: Unordered, Open by value:url
url		1..1	uri	Por quê o valor esperado não está presente
effectiveDateTime			dateTime
effectivePeriod			Period
effectiveTiming			Timing
effectiveInstant			instant
issued	Σ	0..1	instant	Data/hora em que esta versão foi disponibilizada
performer	Σ	0..*	Reference(BRCorePractitioner | BRCorePractitionerRole | BRCoreOrganization | CareTeam | BRCorePatient | BRCoreRelatedPerson)	Quem é o responsável pela observação
value[x]	ΣC	0..1		Resultado da observação
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Por quê o resultado está faltando Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	Interpretação do resultado Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comentários sobre a observação
bodySite		0..1	CodeableConcept	Parte anatômica alvo da observação Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	Método de medição Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(BRCoreSpecimen)	Amostra utilizada para esta observação
device		0..1	Reference(Device | DeviceMetric)	Dispositivo de medida da observação
referenceRange	C	0..*	BackboneElement	Fornece um guia para interpretação obs-3: Must have at least a low or a high or text
id		0..1	string	Identificador único para referenciação cruzada
extension		0..*	Extension	Extensões adicionais que não fazem parte do modelo de dados básico
modifierExtension	?!Σ	1..1	Extension	Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas
low	C	0..1	SimpleQuantity	Limite inferior do intervalo
high	C	0..1	SimpleQuantity	Limite superior do intervalo
type		0..1	CodeableConcept	Qualificador do valor de referência Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	População do intervalo de referência Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Faixa etária aplicável
text		1..1	string	Intervalo de referência em formato textual
hasMember	Σ	0..*	Reference(BRCoreObservation | QuestionnaireResponse | MolecularSequence)	Recurso relacionado que pertence a observação
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | BRCoreObservation | MolecularSequence)	Medições relacionadas a partir das quais a observação é feita
component	Σ	0..*	BackboneElement	Resultados do componente
id		0..1	string	ID exclusivo para referência entre elementos
extension		0..*	Extension	Conteúdo adicional definido por implementações
modifierExtension	?!Σ	0..*	Extension	Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas
code	Σ	1..1	CodeableConcept	Tipo do componente da observação Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Resultado do componente
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Por que o resultado do componente está ausente Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	Interpretação do resultado do componente Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Valores de referência
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 from the FHIR Standard
Observation.category	preferred	ObservationCategoryCodes http://hl7.org/fhir/ValueSet/observation-category from the FHIR Standard
Observation.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard
Observation.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Observation.method	example	ObservationMethods http://hl7.org/fhir/ValueSet/observation-methods from the FHIR Standard
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning from the FHIR Standard
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto from the FHIR Standard
Observation.component.code	example	LOINCCodes (a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes from the FHIR Standard
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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 : 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()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
obs-3	error	Observation.referenceRange	Must have at least a low or a high or text : low.exists() or high.exists() or text.exists()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Esta estrutura é derivada de BRCoreObservation

Summary

Fixed: 1 element