Guia de Implementação da SES GO - CORE - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: Exame Avaliado

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
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Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Exame avaliado Binding: Exame (required) ele-1: All FHIR elements must have a @value or children
encounter	Σ	1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado ele-1: All FHIR elements must have a @value or children
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência ele-1: All FHIR elements must have a @value or children
conclusion		0..1	string	Interpretação do resultado ele-1: All FHIR elements must have a @value or children
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	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	DiagnosticReport	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	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	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 DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
code		1..1	CodeableConcept	Exame avaliado Binding: Exame (required)
encounter		1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência
conclusion		0..1	string	Interpretação do resultado
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
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	Business identifier for report
basedOn		0..*	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	Σ	0..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code	Σ	1..1	CodeableConcept	Exame avaliado Binding: Exame (required)
subject	Σ	0..1	Reference(Patient | Group | Device | Location)	The subject of the report - usually, but not always, the patient
encounter	Σ	1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	Σ	0..*	BackboneElement	Key images associated with this report
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
comment		0..1	string	Comment about the image (e.g. explanation)
link	Σ	1..1	Reference(Media)	Reference to the image source
conclusion		0..1	string	Interpretação do resultado
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required)
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	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	DiagnosticReport	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	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	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 DiagnosticReport

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

• Consulta acompanhamento gestante (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/consulta-acompanhamento-gestante)
• Exame Simples (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/exame-simples)
• Exame Composto (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/exame-composto)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	CodeableConcept	Exame avaliado Binding: Exame (required) ele-1: All FHIR elements must have a @value or children
encounter	Σ	1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado ele-1: All FHIR elements must have a @value or children
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência ele-1: All FHIR elements must have a @value or children
conclusion		0..1	string	Interpretação do resultado ele-1: All FHIR elements must have a @value or children
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	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	DiagnosticReport	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	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	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 DiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
code		1..1	CodeableConcept	Exame avaliado Binding: Exame (required)
encounter		1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência
conclusion		0..1	string	Interpretação do resultado
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	DiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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 Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
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	Business identifier for report
basedOn		0..*	Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	What was requested
status	?!Σ	1..1	code	registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	Σ	0..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code	Σ	1..1	CodeableConcept	Exame avaliado Binding: Exame (required)
subject	Σ	0..1	Reference(Patient | Group | Device | Location)	The subject of the report - usually, but not always, the patient
encounter	Σ	1..1	Reference(Consulta acompanhamento gestante)	Informações do exame avaliado
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Responsible Diagnostic Service
resultsInterpreter	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | CareTeam)	Primary result interpreter
specimen		0..*	Reference(Specimen)	Specimens this report is based on
result		0..1	Reference(Exame Simples | Exame Composto)	Resultado de referência
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	Σ	0..*	BackboneElement	Key images associated with this report
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
comment		0..1	string	Comment about the image (e.g. explanation)
link	Σ	1..1	Reference(Media)	Reference to the image source
conclusion		0..1	string	Interpretação do resultado
conclusionCode		0..*	CodeableConcept	Interpretação codificada Binding: Conjunto de códigos CID10 e CIAP2 (required)
presentedForm		0..*	Attachment	Entire report as issued
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DiagnosticReport.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DiagnosticReport.status	required	DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard
DiagnosticReport.category	example	DiagnosticServiceSectionCodes http://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard
DiagnosticReport.code	required	Exame https://fhir.saude.go.gov.br/r4/core/ValueSet/exame from this IG
DiagnosticReport.conclusionCode	required	CID10CIAP2 https://fhir.saude.go.gov.br/r4/core/ValueSet/cid10-ciap2 from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DiagnosticReport	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DiagnosticReport	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	DiagnosticReport	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	DiagnosticReport	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DiagnosticReport	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 DiagnosticReport

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

• Consulta acompanhamento gestante (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/consulta-acompanhamento-gestante)
• Exame Simples (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/exame-simples)
• Exame Composto (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/exame-composto)

Other representations of profile: CSV, Excel, Schematron