{
"description": null,
"_filename": "Profile/ClinicalImpressionPTCore.StructureDefinition.json",
"package_name": "package.teste",
"date": "2024-06-19T16:32:00.2848052+00:00",
"derivation": "constraint",
"publisher": "SPMS",
"fhirVersion": "4.3.0",
"name": "ClinicalImpressionPTCore",
"abstract": false,
"type": "ClinicalImpression",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "Clinical Impression PT Core",
"package_version": "1.0.2-draft",
"status": "draft",
"id": "78f61869-66bc-46e0-9b74-33c5eb2be3e8",
"kind": "resource",
"url": "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore",
"version": "1.0.0",
"differential": {
"element": [ {
"id": "ClinicalImpression.meta",
"path": "ClinicalImpression.meta",
"type": [ {
"code": "Meta",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/MetaPTCore" ]
} ],
"definition": "Os metadados sobre o recurso."
}, {
"id": "ClinicalImpression.identifier",
"path": "ClinicalImpression.identifier",
"type": [ {
"code": "Identifier",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/IdentifierPTCore" ]
} ],
"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."
}, {
"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",
"type": [ {
"code": "CodeableConcept",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore" ]
} ],
"definition": "O motivo do estado atual do ClinicalImpression."
}, {
"id": "ClinicalImpression.code",
"path": "ClinicalImpression.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore" ]
} ],
"definition": "Categoriza o tipo de avaliação clínica realizada."
}, {
"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",
"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" ]
} ],
"definition": "O utente ou grupo de indivíduos avaliados como parte deste registro."
}, {
"id": "ClinicalImpression.encounter",
"path": "ClinicalImpression.encounter",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/EncounterPTCore" ]
} ],
"definition": "O Encounter durante o qual este ClinicalImpression foi criado ou ao qual a criação deste registo está fortemente associada."
}, {
"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",
"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" ]
} ],
"definition": "O médico que realiza a avaliação."
}, {
"id": "ClinicalImpression.previous",
"path": "ClinicalImpression.previous",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClinicalImpression", "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ClinicalImpressionPTCore" ]
} ],
"definition": "Uma referência à última avaliação realizada neste paciente"
}, {
"id": "ClinicalImpression.problem",
"path": "ClinicalImpression.problem",
"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" ]
} ],
"definition": "Uma lista dos problemas/condições relevantes para um paciente."
}, {
"id": "ClinicalImpression.investigation",
"path": "ClinicalImpression.investigation",
"definition": "Um ou mais conjuntos de investigações (sinais, sintomas, etc.)."
}, {
"id": "ClinicalImpression.investigation.code",
"path": "ClinicalImpression.investigation.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore" ]
} ],
"definition": "Um nome/código para o grupo (\"conjunto\") de investigações."
}, {
"id": "ClinicalImpression.investigation.item",
"path": "ClinicalImpression.investigation.item",
"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" ]
} ],
"definition": "Um registo de uma investigação específica que foi realizada."
}, {
"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",
"type": [ {
"code": "CodeableConcept",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore" ]
} ],
"definition": "Texto ou código específico para descoberta ou diagnóstico, que pode incluir condições descartadas ou resolvidas."
}, {
"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",
"type": [ {
"code": "CodeableConcept",
"profile": [ "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/CodeableConceptPTCore" ]
} ],
"definition": "Estimativa do resultado provável."
}, {
"id": "ClinicalImpression.prognosisReference",
"path": "ClinicalImpression.prognosisReference",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/RiskAssessment", "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RiskAssessmentPTCore" ]
} ],
"definition": "RiskAssessment que expressa o resultado provável."
}, {
"id": "ClinicalImpression.supportingInfo",
"path": "ClinicalImpression.supportingInfo",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource", "https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/ResourcePTCore" ]
} ],
"definition": "Informações que apoiam a avaliação clínica."
}, {
"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."
} ]
},
"contact": [ {
"name": "Interoperabilidade Semântica",
"telecom": [ {
"value": "https://www.spms.min-saude.pt",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
}