ID lógico deste artefato

Metadados adicionais sobre o recurso

A linguagem humana natural do recurso

Um texto narrativo resumindo as informações do recurso

ID lógico deste artefato

Instancia o protocolo ou definição FHIR

Instancia protocolo externo ou definição

Que pedido atende

Qual solicitação substitui

ID de solicitação composta

draft | active | on-hold | revoked | completed | entered-in-error | unknown

proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option

Códigos que indicam o grau de autoridade/intencionalidade associado a uma solicitação.

routine | urgent | asap | stat

Verdadeiro se o serviço/procedimento não deve ser executado

What is being requested/ordered

Informações adicionais sobre o pedido

Valor do serviço

Indivíduo ou entidade para a qual o serviço é solicitado

Encontro em que a solicitação foi criada

Quando o serviço deve ocorrer

Pré-condições para o serviço

Data de solicitação assinada

Quem/o que está solicitando o serviço

Papel do performador

Performador solicitado

Localização solicitada

Localização solicitada

Explicação/Justificativa para procedimento ou serviço

Explicação/Justificativa para serviço ou assistência

Cobertura de seguro associada

Informações clínicas adicionais

Amostras de Procedimentos

Localização no corpo

Comentários

Instruções orientadas para o paciente ou consumidor

Solicitar proveniência

A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

ID 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 adicionais sobre o recurso

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

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.

A linguagem humana natural 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.

Um texto narrativo resumindo as informações do recurso

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.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

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.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID lógico deste artefato

The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.

Instancia o protocolo ou definição FHIR

Note: 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.

Instancia protocolo externo ou definição

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Que pedido atende

Qual solicitação substitui

ID de solicitação composta

Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.

Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes.

draft | active | on-hold | revoked | completed | entered-in-error | unknown

The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource.

The status of a service order.

proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

The kind of service request.

Códigos que indicam o grau de autoridade/intencionalidade associado a uma solicitação.

There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.

Used for filtering what service request are retrieved and displayed.

routine | urgent | asap | stat

Verdadeiro se o serviço/procedimento não deve ser executado

In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.

Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.

What is being requested/ordered

Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code.

Informações adicionais sobre o pedido

For information from the medical record intended to support the delivery of the requested services, use the supportingInformation element.

Codified order entry details which are based on order context.

Valor do serviço

When ordering a service the number of service items may need to be specified separately from the the service item.

Indivíduo ou entidade para a qual o serviço é solicitado

Encontro em que a solicitação foi criada

Quando o serviço deve ocorrer

Pré-condições para o serviço

A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc.

Data de solicitação assinada

Quem/o que está solicitando o serviço

This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource.

Papel do performador

This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”.

Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc.

Performador solicitado

If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B).

Localização solicitada

A location type where services are delivered.

Localização solicitada

Explicação/Justificativa para procedimento ou serviço

This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use CodeableConcept.text element if the data is free (uncoded) text as shown in the CT Scan example.

Diagnosis or problem codes justifying the reason for requesting the service investigation.

Explicação/Justificativa para serviço ou assistência

This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in DiagnosticReport.conclusion and/or DiagnosticReport.conclusionCode. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in ServiceRequest.reasonCode if the data is free (uncoded) text as shown in the CT Scan example.

Cobertura de seguro associada

Informações clínicas adicionais

To represent information about how the services are to be delivered use the instructions element.

Amostras de Procedimentos

Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.

Localização no corpo

Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure.

Codes describing anatomical locations. May include laterality.

Knowing where the procedure is performed is important for tracking if multiple sites are possible.

Comentários

Instruções orientadas para o paciente ou consumidor

Solicitar proveniência

This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.

A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

ID 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 adicionais sobre o recurso

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

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.

A linguagem humana natural 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.

Um texto narrativo resumindo as informações do recurso

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.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

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.

May be used to represent additional information that is not part of the basic definition of the resource. 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.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

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.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID lógico deste artefato

The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.

Instancia o protocolo ou definição FHIR

Note: 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.

Instancia protocolo externo ou definição

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Que pedido atende

Qual solicitação substitui

ID de solicitação composta

Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.

Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes.

draft | active | on-hold | revoked | completed | entered-in-error | unknown

The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource.

The status of a service order.

proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

The kind of service request.

Códigos que indicam o grau de autoridade/intencionalidade associado a uma solicitação.

There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.

Used for filtering what service request are retrieved and displayed.

routine | urgent | asap | stat

Verdadeiro se o serviço/procedimento não deve ser executado

In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.

Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.

What is being requested/ordered

Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code.

Informações adicionais sobre o pedido

For information from the medical record intended to support the delivery of the requested services, use the supportingInformation element.

Codified order entry details which are based on order context.

Valor do serviço

When ordering a service the number of service items may need to be specified separately from the the service item.

Indivíduo ou entidade para a qual o serviço é solicitado

Encontro em que a solicitação foi criada

Quando o serviço deve ocorrer

Pré-condições para o serviço

A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc.

Data de solicitação assinada

Quem/o que está solicitando o serviço

This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource.

Papel do performador

This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”.

Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc.

Performador solicitado

If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B).

Localização solicitada

A location type where services are delivered.

Localização solicitada

Explicação/Justificativa para procedimento ou serviço

This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use CodeableConcept.text element if the data is free (uncoded) text as shown in the CT Scan example.

Diagnosis or problem codes justifying the reason for requesting the service investigation.

Explicação/Justificativa para serviço ou assistência

This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in DiagnosticReport.conclusion and/or DiagnosticReport.conclusionCode. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in ServiceRequest.reasonCode if the data is free (uncoded) text as shown in the CT Scan example.

Cobertura de seguro associada

Informações clínicas adicionais

To represent information about how the services are to be delivered use the instructions element.

Amostras de Procedimentos

Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.

Localização no corpo

Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure.

Codes describing anatomical locations. May include laterality.

Knowing where the procedure is performed is important for tracking if multiple sites are possible.

Comentários

Instruções orientadas para o paciente ou consumidor

Solicitar proveniência

This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.