Guia de Implementação da SES GO - CORE
1.2.6 - draft Brazil flag

Guia de Implementação da SES GO - CORE - Downloaded Version 1.2.6 See the Directory of published versions

Resource Profile: Diagnóstico do Sumário de Alta

Official URL: https://fhir.saude.go.gov.br/r4/core/StructureDefinition/diagnostico-sumario-alta Version: 1.2.6
Draft as of 2026-03-07 Computable Name: DiagnosticoSumarioAlta

Registro estruturado dos diagnósticos identificados que tenham influência direta na conduta terapêutica adotada ou no prognóstico do paciente.

Usos:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!ΣC 0..1 CodeableConcept Estado de resolução
Vínculo: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... system Σ 1..1 uri Identity of the terminology system
..... code Σ 1..1 code Symbol in syntax defined by the system
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Vínculo: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 1..1 CodeableConcept Categoria do diagnóstico
Vínculo: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... code Σ 1..1 code Symbol in syntax defined by the system
... code Σ 1..1 CodeableConcept Código do diagnóstico
Vínculo: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... system Σ 1..1 uri Terminologia que descreve o diagnóstico
..... code Σ 1..1 code Symbol in syntax defined by the system
... subject Σ 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter Σ 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... recordedDate Σ 1..1 dateTime Data e hora da saída da internação

doco Documentação para este formato

Terminologia Ligações

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 a norma FHIR
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 a norma FHIR
Condition.category Base extensible Condition Category Codes 📍4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 a norma FHIR
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0

Restrições

Id Grau Caminho(s) Descrição Expressão
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Condition

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus 0..1 CodeableConcept Estado de resolução
.... coding 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... system 1..1 uri Identity of the terminology system
..... code 1..1 code Symbol in syntax defined by the system
... category 1..1 CodeableConcept Categoria do diagnóstico
.... coding 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... code 1..1 code Symbol in syntax defined by the system
... code 1..1 CodeableConcept Código do diagnóstico
.... coding 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... system 1..1 uri Terminologia que descreve o diagnóstico
..... code 1..1 code Symbol in syntax defined by the system
... subject 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... recordedDate 1..1 dateTime Data e hora da saída da internação

doco Documentação para este formato

Terminologia Ligações (Diferencial)

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0
NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!ΣC 0..1 CodeableConcept Estado de resolução
Vínculo: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 1..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Vínculo: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 1..1 CodeableConcept Categoria do diagnóstico
Vínculo: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Vínculo: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code Σ 1..1 CodeableConcept Código do diagnóstico
Vínculo: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 1..1 uri Terminologia que descreve o diagnóstico
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Vínculo: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject Σ 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter Σ 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... onset[x] Σ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 1..1 dateTime Data e hora da saída da internação
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Vínculo: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Vínculo: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Vínculo: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentação para este formato

Terminologia Ligações

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.language Base preferred Common Languages 📍4.0.1 a norma FHIR
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 a norma FHIR
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 a norma FHIR
Condition.category Base extensible Condition Category Codes 📍4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 a norma FHIR
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 a norma FHIR
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 a norma FHIR
Condition.stage.summary Base example Condition Stage 📍4.0.1 a norma FHIR
Condition.stage.type Base example Condition Stage Type 📍4.0.1 a norma FHIR
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 a norma FHIR

Restrições

Id Grau Caminho(s) Descrição Expressão
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Condition

Key Elements View

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!ΣC 0..1 CodeableConcept Estado de resolução
Vínculo: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... system Σ 1..1 uri Identity of the terminology system
..... code Σ 1..1 code Symbol in syntax defined by the system
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Vínculo: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 1..1 CodeableConcept Categoria do diagnóstico
Vínculo: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... code Σ 1..1 code Symbol in syntax defined by the system
... code Σ 1..1 CodeableConcept Código do diagnóstico
Vínculo: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... system Σ 1..1 uri Terminologia que descreve o diagnóstico
..... code Σ 1..1 code Symbol in syntax defined by the system
... subject Σ 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter Σ 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... recordedDate Σ 1..1 dateTime Data e hora da saída da internação

doco Documentação para este formato

Terminologia Ligações

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 a norma FHIR
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 a norma FHIR
Condition.category Base extensible Condition Category Codes 📍4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 a norma FHIR
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0

Restrições

Id Grau Caminho(s) Descrição Expressão
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from Condition

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus 0..1 CodeableConcept Estado de resolução
.... coding 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... system 1..1 uri Identity of the terminology system
..... code 1..1 code Symbol in syntax defined by the system
... category 1..1 CodeableConcept Categoria do diagnóstico
.... coding 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... code 1..1 code Symbol in syntax defined by the system
... code 1..1 CodeableConcept Código do diagnóstico
.... coding 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... system 1..1 uri Terminologia que descreve o diagnóstico
..... code 1..1 code Symbol in syntax defined by the system
... subject 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... recordedDate 1..1 dateTime Data e hora da saída da internação

doco Documentação para este formato

Terminologia Ligações (Diferencial)

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0

Snapshot View

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!ΣC 0..1 CodeableConcept Estado de resolução
Vínculo: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: ConditionClinicalStatusCodes (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 1..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Vínculo: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 1..1 CodeableConcept Categoria do diagnóstico
Vínculo: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Categoria do Diagnóstico (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Vínculo: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code Σ 1..1 CodeableConcept Código do diagnóstico
Vínculo: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 1..* Coding Code defined by a terminology system
Vínculo: Classificação Internacional de Doenças - Décima Revisão - CID-10 (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 1..1 uri Terminologia que descreve o diagnóstico
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Vínculo: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject Σ 1..1 Reference(Cidadão Identificado) Identificação do Indivíduo
... encounter Σ 1..1 Reference(Contato Assistencial do Sumário de Alta) Encounter created as part of
... onset[x] Σ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 1..1 dateTime Data e hora da saída da internação
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Vínculo: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Vínculo: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Vínculo: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentação para este formato

Terminologia Ligações

Caminho Estado Utilização Conjunto de valores Versão Fonte
Condition.language Base preferred Common Languages 📍4.0.1 a norma FHIR
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 a norma FHIR
Condition.clinicalStatus.​coding Base required Condition Clinical Status Codes 📦4.0.1 a norma FHIR
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 a norma FHIR
Condition.category Base extensible Condition Category Codes 📍4.0.1 a norma FHIR
Condition.category.coding Base required Categoria do Diagnóstico 📦1.0.3 REDS GO v1.0
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 a norma FHIR
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 a norma FHIR
Condition.code.coding Base required Classificação Internacional de Doenças - Décima Revisão - CID-10 📦1.0.3 REDS GO v1.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 a norma FHIR
Condition.stage.summary Base example Condition Stage 📍4.0.1 a norma FHIR
Condition.stage.type Base example Condition Stage Type 📍4.0.1 a norma FHIR
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 a norma FHIR

Restrições

Id Grau Caminho(s) Descrição Expressão
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Condition

 

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