description: Documento clínico utilizado para representar el conjunto de datos del Resumen Internacional de Pacientes (IPS). \nUn documento de Resumen Internacional de Paciente (IPS) es un extracto de historia clínica electrónica que contiene información sanitaria esencial sobre un sujeto de atención. \nEl conjunto de datos IPS es mínimo y no exhaustivo; independiente de la especialidad y la afección; pero sigue siendo clínicamente relevante. Tal como se especifica en las normas EN 17269 e ISO 27269, está diseñado para apoyar el caso de uso de la «atención transfronteriza no planificada», pero no se limita a él. Pretende ser internacional, es decir, ofrecer soluciones genéricas para su aplicación global más allá de una región o país concretos. package_name: hl7.fhir.cl.clips derivation: constraint name: DocumentoClIps type: Composition elements: date: {short: Hora de edición de la composición, index: 5} section: short: Secciones que componen el IPS array: true min: 3 index: 20 elements: code: {type: CodeableConcept, index: 21} text: {index: 22} emptyReason: {mustSupport: false, index: 23} section: {mustSupport: false, index: 24} required: [text, code] slicing: rules: open ordered: false discriminator: - {path: code, type: pattern} min: 3 slices: sectionDispMedicos: match: code: coding: - {code: 46264-8, system: 'http://loinc.org'} schema: short: Sección de Dispositivos Médicos mustSupport: true index: 51 elements: title: {mustSupport: true, index: 52} code: pattern: type: CodeableConcept value: coding: - {code: 46264-8, system: 'http://loinc.org'} index: 53 entry: type: Reference short: La historia de dispositivos médicos en uso refers: ['http://hl7.org/fhir/StructureDefinition/DeviceUseStatement', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 54 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: deviceStatement: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Declaracion-uso-dispositivo-cl-ips'] array: true min: 1 _required: true index: 55 min: 1 required: [entry, title] sectionMedicamentos: match: code: coding: - {code: 10160-0, system: 'http://loinc.org'} schema: short: Sección de Resumen de Medicamentos IPS mustSupport: true _required: true index: 25 elements: title: {short: Sección de Resumen de Medicamentos, mustSupport: true, index: 26} code: pattern: type: CodeableConcept value: coding: - {code: 10160-0, system: 'http://loinc.org'} index: 27 entry: type: Reference short: Medicamentos relevantes para la salud del paciente refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/MedicationAdministration', 'http://hl7.org/fhir/StructureDefinition/MedicationDispense', 'http://hl7.org/fhir/StructureDefinition/MedicationRequest', 'http://hl7.org/fhir/StructureDefinition/MedicationStatement'] index: 28 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: listMedicamentos: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/RegMedicamentos-cl-ips'] array: true index: 29 min: 0 prescripciones: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/MedicationRequest-cl-ips'] array: true index: 30 min: 0 required: [entry, title] sectionDirectivasAvanzadas: match: code: coding: - {code: 42348-3, system: 'http://loinc.org'} schema: short: Sección de Consentimientos index: 101 elements: title: {index: 102} code: pattern: type: CodeableConcept value: coding: - {code: 42348-3, system: 'http://loinc.org'} index: 103 entry: type: Reference short: Descripción narrativa del documento de declaraciones de acceso del paciente. refers: ['http://hl7.org/fhir/StructureDefinition/Consent', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 104 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: advanceDirectivesConsent: match: {} schema: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/Consent'] array: true index: 105 min: 0 required: [title] sectionFlagAlerts: match: code: coding: - {code: 104605-1, system: 'http://loinc.org'} schema: short: Flag - Alertas index: 96 elements: title: {index: 97} code: pattern: type: CodeableConcept value: coding: - {code: 104605-1, system: 'http://loinc.org'} index: 98 entry: type: Reference short: Información sobre alertas relacionadas al paciente. refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Flag'] index: 99 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: alertsFlag: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Flag-alerta-cl-ips'] array: true index: 100 min: 0 required: [title] sectionResultados: match: code: coding: - {code: 30954-2, system: 'http://loinc.org'} schema: short: Sección de Resultados mustSupport: true index: 56 elements: title: {mustSupport: true, index: 57} code: pattern: type: CodeableConcept value: coding: - {code: 30954-2, system: 'http://loinc.org'} index: 58 entry: type: Reference short: Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Observation'] index: 59 slicing: rules: open discriminator: - {path: resolve(), type: type} - {path: resolve(), type: profile} min: 1 slices: resultados-obs-lab-pato: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-resultado-laboratorio-patologico-cl-ips'] array: true index: 60 min: 0 resultados-obs-radio: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-resultado-radiology-cl-ips'] array: true index: 61 min: 0 resultado-reporte: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/DiagnosticReport-cl-ips'] array: true index: 62 min: 0 required: [entry, title] sectionEmbarazoHx: match: code: coding: - {code: 10162-6, system: 'http://loinc.org'} schema: short: Historial de Embarazos index: 90 elements: title: {index: 91} code: pattern: type: CodeableConcept value: coding: - {code: 10162-6, system: 'http://loinc.org'} index: 92 entry: type: Reference short: Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Observation'] index: 93 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: statusEmbarazo: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-estado-del-embarazo-cl-ips'] array: true index: 94 min: 0 resultadoEmbarazo: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-resultado-del-embarazo-cl-ips'] array: true index: 95 min: 0 required: [title] sectionAlergias: match: code: coding: - {code: 48765-2, system: 'http://loinc.org'} schema: short: Sección de Alergias e Intolerancias mustSupport: true _required: true index: 31 elements: title: {mustSupport: true, index: 32} code: pattern: type: CodeableConcept value: coding: - {code: 48765-2, system: 'http://loinc.org'} index: 33 entry: type: Reference short: Alergias o intolerancias (afecciones) relevantes para ese paciente. refers: ['http://hl7.org/fhir/StructureDefinition/AllergyIntolerance', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 34 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: alergias: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/AllergiaInt-cl-ips'] array: true min: 1 _required: true index: 35 min: 1 required: [entry, title] sectionHistoricoHx: match: code: coding: - {code: 11348-0, system: 'http://loinc.org'} schema: short: Histórico de enfermedades index: 68 elements: title: {index: 69} code: pattern: type: CodeableConcept value: coding: - {code: 11348-0, system: 'http://loinc.org'} index: 70 entry: type: Reference short: Condiciones sufridas por el paciente en el pasado refers: ['http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 71 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: pastProblem: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Condition-cl-ips'] array: true min: 1 _required: true index: 72 min: 1 required: [entry, title] sectionStatusFuncional: match: code: coding: - {code: 47420-5, system: 'http://loinc.org'} schema: short: Status Funcional index: 73 elements: title: {index: 74} code: pattern: type: CodeableConcept value: coding: - {code: 47420-5, system: 'http://loinc.org'} index: 75 entry: type: Reference short: Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression', 'http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 76 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: discapacidad: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Condition-cl-ips'] array: true index: 77 min: 0 evalFuncional: match: {} schema: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression'] array: true index: 78 min: 0 required: [title] sectionSignosVitales: match: code: coding: - {code: 8716-3, system: 'http://loinc.org'} schema: short: Sección de Signos Vitales label: Signos Vitales index: 63 elements: title: {index: 64} code: pattern: type: CodeableConcept value: coding: - {code: 8716-3, system: 'http://loinc.org'} index: 65 entry: type: Reference short: Signos vitales o hallazgos físicos de interés. refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Observation'] index: 66 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: vitalSign: match: {} schema: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns'] array: true index: 67 min: 0 required: [title] sectionProblemas: match: code: coding: - {code: 11450-4, system: 'http://loinc.org'} schema: short: Problemas de Salud mustSupport: true _required: true index: 36 elements: title: {mustSupport: true, index: 37} code: pattern: type: CodeableConcept value: coding: - {code: 11450-4, system: 'http://loinc.org'} index: 38 entry: type: Reference short: Problemas o afecciones clínicas que se están controlando actualmente en el paciente. refers: ['http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 39 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: problema: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Condition-cl-ips'] array: true min: 1 _required: true index: 40 min: 1 required: [entry, title] sectionImmunizaciones: match: code: coding: - {code: 11369-6, system: 'http://loinc.org'} schema: short: Sección de Inmunizaciones mustSupport: true index: 46 elements: title: {mustSupport: true, index: 47} code: pattern: type: CodeableConcept value: coding: - {code: 11369-6, system: 'http://loinc.org'} index: 48 entry: type: Reference short: Estado de vacunación del paciente y antecedentes pertinentes. refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Immunization'] index: 49 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: immunizacion: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Inmunizacion-cl-ips'] array: true min: 1 _required: true index: 50 min: 1 required: [entry, title] sectionProcedimientos: match: code: coding: - {code: 47519-4, system: 'http://loinc.org'} schema: short: Historial de Procedimientos mustSupport: true index: 41 elements: title: {mustSupport: true, index: 42} code: pattern: type: CodeableConcept value: coding: - {code: 47519-4, system: 'http://loinc.org'} index: 43 entry: type: Reference short: Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 44 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: 1 slices: procedimiento: match: {} schema: type: Reference mustSupport: true refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Procedimientos-cl-ips'] array: true min: 1 _required: true index: 45 min: 1 required: [entry, title] sectionHistoriaSocial: match: code: coding: - {code: 29762-2, system: 'http://loinc.org'} schema: short: Historia Social index: 84 elements: title: {index: 85} code: pattern: type: CodeableConcept value: coding: - {code: 29762-2, system: 'http://loinc.org'} index: 86 entry: type: Reference short: Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) refers: ['http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Observation'] index: 87 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: fumador: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-uso-de-tabaco-cl-ips'] index: 88 min: 0 max: 1 alcohol: match: {} schema: type: Reference refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-uso-de-alcohol-cl-ips'] index: 89 min: 0 max: 1 required: [title] sectionPlanCuidado: match: code: coding: - {code: 18776-5, system: 'http://loinc.org'} schema: short: Plan de Cuidado index: 79 elements: title: {index: 80} code: pattern: type: CodeableConcept value: coding: - {code: 18776-5, system: 'http://loinc.org'} index: 81 entry: type: Reference short: Resumen de plan de cuidados refers: ['http://hl7.org/fhir/StructureDefinition/CarePlan', 'http://hl7.org/fhir/StructureDefinition/DocumentReference'] index: 82 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: carePlan: match: {} schema: type: Reference refers: ['http://hl7.org/fhir/StructureDefinition/CarePlan'] array: true index: 83 min: 0 required: [title] attester: short: Atestigua la exactitud de la composición index: 8 elements: time: {short: Hora y fecha que atestigua el composición, index: 9} party: {short: Quien atestigua la composición, index: 10} type: type: CodeableConcept short: Tipo de Documento ("Resumen de Paciente") pattern: type: CodeableConcept value: coding: - {code: 60591-5, system: 'http://loinc.org'} index: 2 title: {short: International Patient Summary Genérico para uso en Chile, index: 7} author: {short: Quién y/o qué fue el autor del IPS, index: 6} event: short: El(los) servicio(s) clínico(s) que están siendo documentados index: 16 slicing: rules: open discriminator: - {path: code, type: pattern} min: null slices: careProvisioningEvent: match: code: coding: - {code: PCPR, system: 'http://terminology.hl7.org/CodeSystem/v3-ActClass'} schema: short: La asistencia descrita en el documento mustSupport: true index: 17 elements: code: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: PCPR, system: 'http://terminology.hl7.org/CodeSystem/v3-ActClass'} index: 18 period: {mustSupport: true, index: 19} required: [code] custodian: {short: Organización que mantiente la composición, index: 11} identifier: {short: Identificador independiente de la versión para la Composición, index: 1} relatesTo: elements: target: short: Objetivo de la relación choices: [targetIdentifier, targetReference] index: 13 targetIdentifier: {type: Identifier, short: Objetivo de la relación, choiceOf: target, index: 14} targetReference: type: Reference short: Objetivo de la relación choiceOf: target refers: ['http://hl7.org/fhir/StructureDefinition/Composition', 'https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Composition-cl-ips'] index: 15 subject: type: Reference short: Quién y/o qué trata la composición refers: ['https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Paciente-cl-ips'] index: 3 elements: reference: {short: 'Referencia literal, interna o url absoluta', mustSupport: true, index: 4} required: [reference] text: {short: 'Resumen de texto del recurso, para interpretación humana', mustSupport: true, index: 0} package_version: 0.3.0-ballot class: profile kind: resource url: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Composition-cl-ips base: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl version: 0.3.0-ballot required: [subject]