{ "description": "Descrições textuais simples sobre um paciente.", "_filename": "structuredefinition-br-core-observationtext.json", "package_name": "BRCore", "date": "2020-06-09T17:52:53.0098607+00:00", "derivation": "constraint", "meta": { "lastUpdated": "2020-06-09T17:52:28.104+00:00" }, "publisher": "Ministério da Saúde do Brasil", "fhirVersion": "4.0.0", "name": "BRObservacaoDescritiva", "abstract": false, "type": "Observation", "experimental": null, "resourceType": "StructureDefinition", "title": "Observação Descritiva", "package_version": "01.00.00-1.0.0", "status": "active", "language": "pt-BR", "id": "e9342053-cbdb-4ed6-8140-0fde1719e192", "kind": "resource", "url": "http://www.saude.gov.br/fhir/r4/StructureDefinition/BRObservacaoDescritiva-1.0", "version": "1.0", "differential": { "element": [ { "id": "Observation", "path": "Observation", "mustSupport": true }, { "id": "Observation.identifier", "max": "0", "path": "Observation.identifier" }, { "id": "Observation.basedOn", "max": "0", "path": "Observation.basedOn" }, { "id": "Observation.partOf", "max": "0", "path": "Observation.partOf" }, { "id": "Observation.status", "path": "Observation.status", "short": "Estado da Observação", "binding": { "strength": "required", "valueSet": "http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoObservacao-1.0", "description": "Estado da Observação" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "definition": "Indica o estado que o contato assistencial se encontra quando é informado para a RNDS.", "mustSupport": true }, { "id": "Observation.category", "max": "1", "min": 1, "path": "Observation.category", "short": "Categoria da Observação", "binding": { "strength": "preferred", "valueSet": "http://www.saude.gov.br/fhir/r4/ValueSet/BRCategoriaObservacao-1.0", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "description": "Categoria da Observação" }, "definition": "Categoriza a observação que está sendo representada." }, { "id": "Observation.category.coding", "max": "1", "min": 1, "path": "Observation.category.coding" }, { "id": "Observation.category.coding.system", "min": 1, "path": "Observation.category.coding.system" }, { "id": "Observation.category.coding.code", "min": 1, "path": "Observation.category.coding.code" }, { "id": "Observation.category.coding.display", "max": "0", "path": "Observation.category.coding.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "id": "Observation.category.coding.userSelected", "max": "0", "path": "Observation.category.coding.userSelected" }, { "id": "Observation.category.text", "max": "0", "path": "Observation.category.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "id": "Observation.code", "path": "Observation.code", "short": "Tipo da Observação", "binding": { "strength": "required", "valueSet": "http://www.saude.gov.br/fhir/r4/CodeSystem/BRTipoObservacao-1.0", "description": "Tipo de Observação" }, "definition": "Classifica o tipo de observação que está sendo representada.", "mustSupport": true }, { "id": "Observation.code.coding", "max": "1", "min": 1, "path": "Observation.code.coding" }, { "id": "Observation.code.coding.system", "min": 1, "path": "Observation.code.coding.system" }, { "id": "Observation.code.coding.code", "min": 1, "path": "Observation.code.coding.code" }, { "id": "Observation.code.coding.display", "max": "0", "path": "Observation.code.coding.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "id": "Observation.code.coding.userSelected", "max": "0", "path": "Observation.code.coding.userSelected" }, { "id": "Observation.code.text", "max": "0", "path": "Observation.code.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "id": "Observation.subject", "min": 1, "path": "Observation.subject", "type": [ { "code": "Reference", "targetProfile": [ "http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0" ] } ], "short": "Sujeito da Observação", "definition": "Quem ou o quê a composição se refere. Pode ser um indivíduo, dispositivo, grupos (de indivíduos, dispositivos etc.).", "mustSupport": true }, { "id": "Observation.subject.reference", "max": "0", "path": "Observation.subject.reference" }, { "id": "Observation.subject.type", "max": "0", "path": "Observation.subject.type", "fixedUri": "Patient" }, { "id": "Observation.subject.identifier", "min": 1, "path": "Observation.subject.identifier" }, { "id": "Observation.subject.identifier.use", "max": "0", "path": "Observation.subject.identifier.use" }, { "id": "Observation.subject.identifier.type", "max": "0", "path": "Observation.subject.identifier.type" }, { "id": "Observation.subject.identifier.system", "min": 1, "path": "Observation.subject.identifier.system" }, { "id": "Observation.subject.identifier.value", "min": 1, "path": "Observation.subject.identifier.value" }, { "id": "Observation.subject.identifier.period", "max": "0", "path": "Observation.subject.identifier.period" }, { "id": "Observation.subject.identifier.assigner", "max": "0", "path": "Observation.subject.identifier.assigner" }, { "id": "Observation.subject.display", "max": "0", "path": "Observation.subject.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "id": "Observation.focus", "max": "0", "path": "Observation.focus" }, { "id": "Observation.encounter", "max": "0", "path": "Observation.encounter" }, { "id": "Observation.effective[x]", "max": "0", "path": "Observation.effective[x]" }, { "id": "Observation.issued", "min": 1, "path": "Observation.issued", "short": "Data/hora da Observação", "definition": "Data ou data e hora que a Observação foi escrita.", "mustSupport": true }, { "id": "Observation.performer", "max": "0", "path": "Observation.performer" }, { "id": "Observation.value[x]", "min": 1, "path": "Observation.value[x]", "type": [ { "code": "string" } ], "alias": [ "Declaração subjetiva do indivíduo para o atendimento", "Resumo da evolução clínica do indivíduo durante a internação", "Dados do desfecho", "Informações adicionais/complementares" ], "short": "Resultado da Observação", "definition": "Descrição textual da observação realizada.", "mustSupport": true }, { "id": "Observation.dataAbsentReason", "max": "0", "path": "Observation.dataAbsentReason" }, { "id": "Observation.interpretation", "max": "0", "path": "Observation.interpretation" }, { "id": "Observation.note", "max": "0", "path": "Observation.note" }, { "id": "Observation.bodySite", "max": "0", "path": "Observation.bodySite" }, { "id": "Observation.method", "max": "0", "path": "Observation.method" }, { "id": "Observation.specimen", "max": "0", "path": "Observation.specimen" }, { "id": "Observation.device", "max": "0", "path": "Observation.device" }, { "id": "Observation.referenceRange", "max": "0", "path": "Observation.referenceRange" }, { "id": "Observation.hasMember", "max": "0", "path": "Observation.hasMember" }, { "id": "Observation.derivedFrom", "max": "0", "path": "Observation.derivedFrom" }, { "id": "Observation.component", "max": "0", "path": "Observation.component" } ] }, "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation" }