description: Definición de un documento para Resumen de Historia o Registro de Encuentro para Historia Clínica, basado en IPS.
package_name: rs/hl7.fhir.cl.clcore
derivation: constraint
name: DocumentoCl
type: Composition
elements:
  date: {short: Fecha en la cual se editó el documento, mustSupport: true, index: 9}
  encounter:
    short: Contexto del Documento.
    mustSupport: true
    index: 5
    elements:
      reference: {short: Corresponde al paciente, mustSupport: true, index: 6}
      identifier: {short: 'Identificador, en formato identifier para el encuentro', mustSupport: true, index: 7}
      display: {short: texto que describe el contexto del documento, mustSupport: true, index: 8}
    required: [reference]
  section:
    short: Sección del documento
    mustSupport: true
    index: 16
    elements:
      code:
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/doc-section-codes'}
        mustSupport: true
        index: 17
    required: [code]
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: code, type: pattern}
      min: 1
      slices:
        sectionDiagnosticos:
          match:
            code:
              coding:
              - {code: 11450-4, system: 'http://loinc.org'}
          schema:
            short: Sección Diagnósticos
            mustSupport: true
            array: true
            index: 18
            elements:
              title: {mustSupport: true, index: 19}
              code:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11450-4, system: 'http://loinc.org'}
                type: CodeableConcept
                index: 20
              entry:
                type: Reference
                short: Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
                mustSupport: true
                refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
                index: 21
            required: [entry, title]
        sectionMedicamentos:
          match:
            code:
              coding:
              - {code: 10160-0, system: 'http://loinc.org'}
          schema:
            short: Sección Medicamentos
            mustSupport: true
            array: true
            index: 22
            elements:
              title: {mustSupport: true, index: 23}
              code:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10160-0, system: 'http://loinc.org'}
                type: CodeableConcept
                index: 24
              entry:
                type: Reference
                short: Referencia al Medicamento Prescrito al paciente.
                mustSupport: true
                refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement']
                index: 25
            required: [entry, title]
        sectionAlergias:
          match:
            code:
              coding:
              - {code: 48765-2, system: 'http://loinc.org'}
          schema:
            short: Sección Alergias y Reacciones Adversas
            mustSupport: true
            array: true
            index: 26
            elements:
              title: {mustSupport: true, index: 27}
              code:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 48765-2, system: 'http://loinc.org'}
                type: CodeableConcept
                index: 28
              entry:
                type: Reference
                short: Alergias e Intolerancia descrita
                mustSupport: true
                refers: ['http://hl7.org/fhir/StructureDefinition/AllergyIntolerance']
                index: 29
            required: [entry, title]
        sectionObservacionEmbarazo:
          match:
            code:
              coding:
              - {code: 10162-6, system: 'http://loinc.org'}
          schema:
            short: Sección Antecedentes de Embarazo
            mustSupport: true
            array: true
            index: 30
            elements:
              title: {mustSupport: true, index: 31}
              code:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10162-6, system: 'http://loinc.org'}
                type: CodeableConcept
                index: 32
              entry:
                type: Reference
                short: Descripción del antecedente de embarzo
                mustSupport: true
                refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                index: 33
            required: [entry, title]
        sectionObservacionSignosVitales:
          match:
            code:
              coding:
              - {code: 8716-3, system: 'http://loinc.org'}
          schema:
            short: Sección de Signos Vitales Medidos
            mustSupport: true
            array: true
            index: 34
            elements:
              title: {mustSupport: true, index: 35}
              code:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 8716-3, system: 'http://loinc.org'}
                type: CodeableConcept
                index: 36
              entry:
                type: Reference
                short: Descripción del los signos vitales y mediciones desarrolladas
                mustSupport: true
                refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                index: 37
            required: [entry, title]
  attester:
    short: Validadores del documento
    mustSupport: true
    index: 12
    elements:
      mode:
        short: Labor del Validador personal|profesional|legal|official
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/composition-attestation-mode'}
        mustSupport: true
        index: 13
      time: {short: Fecha y Hora de la validación, mustSupport: true, index: 14}
      party: {short: Quien validó, mustSupport: true, index: 15}
  type:
    short: 'Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5'
    binding: {strength: required, valueSet: 'https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic'}
    mustSupport: true
    index: 2
  title: {short: Título del documento generado, mustSupport: true, index: 11}
  author:
    type: Reference
    short: Quien Ha creado el documento
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner']
    index: 10
  status:
    short: 'Estado, valores posibles: preliminary | final | amended | entered-in-error'
    mustSupport: true
    pattern: {type: code, value: final}
    type: code
    index: 1
  identifier: {short: Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo, mustSupport: true, index: 0}
  subject:
    type: Reference
    short: Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    index: 3
    elements:
      reference: {short: Corresponde al paciente, mustSupport: true, index: 4}
    required: [reference]
package_version: 1.8.2
class: profile
kind: resource
url: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl
base: http://hl7.org/fhir/StructureDefinition/Composition
version: 1.8.2
required: [section, subject]