FHIR IG Statistics: StructureDefinition/ClinicalImpressionPTCore
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{
"resourceType": "StructureDefinition",
"id": "ClinicalImpressionPTCore",
"url": "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore",
"version": "1.0.0",
"name": "ClinicalImpressionPTCore",
"title": "Clinical Impression PT Core",
"status": "draft",
"date": "2024-06-19T16:32:00.2848052+00:00",
"publisher": "SPMS",
"contact": [
{
"name": "Interoperabilidade Semântica",
"telecom": [
{
"system": "url",
"value": "https://www.spms.min-saude.pt"
}
]
}
],
"fhirVersion": "4.3.0",
"kind": "resource",
"abstract": false,
"type": "ClinicalImpression",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "ClinicalImpression.meta",
"path": "ClinicalImpression.meta",
"definition": "Os metadados sobre o recurso.",
"type": [
{
"code": "Meta",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MetaPTCore"
]
}
]
},
{
"id": "ClinicalImpression.identifier",
"path": "ClinicalImpression.identifier",
"definition": "Identificadores de negócio atribuídos a esta avaliação clínica pelo executor ou outros sistemas que permanecem constantes à medida que o recurso é atualizado e se propaga de servidor para servidor.",
"type": [
{
"code": "Identifier",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/IdentifierPTCore"
]
}
]
},
{
"id": "ClinicalImpression.identifier.type.coding.id",
"path": "ClinicalImpression.identifier.type.coding.id",
"comment": "."
},
{
"id": "ClinicalImpression.status",
"path": "ClinicalImpression.status",
"definition": "Identifica o status do fluxo de trabalho da avaliação."
},
{
"id": "ClinicalImpression.statusReason",
"path": "ClinicalImpression.statusReason",
"definition": "O motivo do estado atual do ClinicalImpression.",
"type": [
{
"code": "CodeableConcept",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
]
}
]
},
{
"id": "ClinicalImpression.code",
"path": "ClinicalImpression.code",
"definition": "Categoriza o tipo de avaliação clínica realizada.",
"type": [
{
"code": "CodeableConcept",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
]
}
]
},
{
"id": "ClinicalImpression.description",
"path": "ClinicalImpression.description",
"definition": "Um resumo do contexto e/ou causa da avaliação – por que/onde ela foi realizada e quais eventos/status do paciente a motivaram."
},
{
"id": "ClinicalImpression.subject",
"path": "ClinicalImpression.subject",
"definition": "O utente ou grupo de indivíduos avaliados como parte deste registro.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient",
"http://hl7.org/fhir/StructureDefinition/Group",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/GroupPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PatientPTCore"
]
}
]
},
{
"id": "ClinicalImpression.encounter",
"path": "ClinicalImpression.encounter",
"definition": "O Encounter durante o qual este ClinicalImpression foi criado ou ao qual a criação deste registo está fortemente associada.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Encounter",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/EncounterPTCore"
]
}
]
},
{
"id": "ClinicalImpression.effective[x]",
"path": "ClinicalImpression.effective[x]",
"definition": "O momento ou período durante o qual o assunto foi avaliado."
},
{
"id": "ClinicalImpression.date",
"path": "ClinicalImpression.date",
"definition": "Indica quando a documentação da avaliação foi concluída."
},
{
"id": "ClinicalImpression.assessor",
"path": "ClinicalImpression.assessor",
"definition": "O médico que realiza a avaliação.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PractitionerPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/PractitionerRolePTCore"
]
}
]
},
{
"id": "ClinicalImpression.previous",
"path": "ClinicalImpression.previous",
"definition": "Uma referência à última avaliação realizada neste paciente",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore"
]
}
]
},
{
"id": "ClinicalImpression.problem",
"path": "ClinicalImpression.problem",
"definition": "Uma lista dos problemas/condições relevantes para um paciente.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition",
"http://hl7.org/fhir/StructureDefinition/AllergyIntolerance",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ConditionPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/AllergyIntolerancePTCore"
]
}
]
},
{
"id": "ClinicalImpression.investigation",
"path": "ClinicalImpression.investigation",
"definition": "Um ou mais conjuntos de investigações (sinais, sintomas, etc.)."
},
{
"id": "ClinicalImpression.investigation.code",
"path": "ClinicalImpression.investigation.code",
"definition": "Um nome/código para o grupo (\"conjunto\") de investigações.",
"type": [
{
"code": "CodeableConcept",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
]
}
]
},
{
"id": "ClinicalImpression.investigation.item",
"path": "ClinicalImpression.investigation.item",
"definition": "Um registo de uma investigação específica que foi realizada.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Observation",
"http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse",
"http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory",
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
"http://hl7.org/fhir/StructureDefinition/RiskAssessment",
"http://hl7.org/fhir/StructureDefinition/ImagingStudy",
"http://hl7.org/fhir/StructureDefinition/Media",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ObservationPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/QuestionnaireResponsePTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/FamilyMemberHistoryPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DiagnosticReportPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RiskAssessmentPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ImagingStudyPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MediaPTCore"
]
}
]
},
{
"id": "ClinicalImpression.protocol",
"path": "ClinicalImpression.protocol",
"definition": "Referência a um protocolo clínico específico publicado que foi seguido durante esta avaliação e/ou que fornece evidências que apoiam o diagnóstico."
},
{
"id": "ClinicalImpression.summary",
"path": "ClinicalImpression.summary",
"definition": "Um resumo em texto das investigações e do diagnóstico."
},
{
"id": "ClinicalImpression.finding",
"path": "ClinicalImpression.finding",
"definition": "Achados ou diagnósticos específicos que foram considerados prováveis ou relevantes para o tratamento contínuo."
},
{
"id": "ClinicalImpression.finding.itemCodeableConcept",
"path": "ClinicalImpression.finding.itemCodeableConcept",
"definition": "Texto ou código específico para descoberta ou diagnóstico, que pode incluir condições descartadas ou resolvidas.",
"type": [
{
"code": "CodeableConcept",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
]
}
]
},
{
"id": "ClinicalImpression.finding.itemReference",
"path": "ClinicalImpression.finding.itemReference",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition",
"http://hl7.org/fhir/StructureDefinition/Observation",
"http://hl7.org/fhir/StructureDefinition/Media",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ConditionPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ObservationPTCore",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MediaPTCore"
]
}
]
},
{
"id": "ClinicalImpression.finding.basis",
"path": "ClinicalImpression.finding.basis",
"definition": "Quais investigações apoiam a descoberta ou o diagnóstico."
},
{
"id": "ClinicalImpression.prognosisCodeableConcept",
"path": "ClinicalImpression.prognosisCodeableConcept",
"definition": "Estimativa do resultado provável.",
"type": [
{
"code": "CodeableConcept",
"profile": [
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore"
]
}
]
},
{
"id": "ClinicalImpression.prognosisReference",
"path": "ClinicalImpression.prognosisReference",
"definition": "RiskAssessment que expressa o resultado provável.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/RiskAssessment",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RiskAssessmentPTCore"
]
}
]
},
{
"id": "ClinicalImpression.supportingInfo",
"path": "ClinicalImpression.supportingInfo",
"definition": "Informações que apoiam a avaliação clínica.",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Resource",
"https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ResourcePTCore"
]
}
]
},
{
"id": "ClinicalImpression.note",
"path": "ClinicalImpression.note",
"definition": "Também podem aparecer comentários sobre a impressão, normalmente registados após a impressão em si, por meio de notas suplementares do autor original."
}
]
}
}
FHIR