Guia de Implementação da SES GO - EXAME
1.0.4 - draft
Guia de Implementação da SES GO - EXAME - Downloaded Version 1.0.4 See the Directory of published versions
| URL oficial: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/laudo-exame | Versão: 1.0.4 | |||
| Draft as of 2026-03-09 | Nome para computador: LaudoExame | |||
Laudo de exame
Usos:
You can also check for usages in the FHIR IG Statistics
Descrição de perfis, diferenças, instantâneo, e como apresentações diferentes funcionam.
Essa estrutura é derivada de DiagnosticReport
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() |
|---|---|---|---|---|
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C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado |
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1..1 | uri | Sistema de origem do exame | |
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1..1 | string | Identificador do exame no sistema de origem | |
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0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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1..1 | code | registered | partial | preliminary | final + Padrão necessário: final | |
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1..1 | uri | Identity of the terminology system | |
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1..1 | code | Exame realizado Vínculo: Exame (required) | |
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0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere | |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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1..1 | instant | Data e hora da realização do exame | |
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2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id | |
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1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo | |
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1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |
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0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor | |
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1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |
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1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo | |
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1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |
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1..1 | Reference(Imagens do Exame) | Reference to the image source | |
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0..1 | base64Binary | Dados do(s) laudo(s) do exame | |
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0..1 | url | Localização(ões) do(s) laudo(s) do exame | |
Documentação para este formato | ||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.code.coding.code | Base | required | Exame | 📦1.0.4 | este IG |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
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?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report. Padrão necessário: final |
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Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Vínculo: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
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Σ | 0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
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Σ | 1..1 | instant | Data e hora da realização do exame |
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Σ | 2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id |
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Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo |
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1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |
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Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor |
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1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |
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Σ | 1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |
Documentação para este formato | ||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | a norma FHIR |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| 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()
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado | ||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Vínculo: CommonLanguages (preferred): A human language.
| |||||
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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Σ | 0..* | Identifier | Business identifier for report | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 0..1 | CodeableConcept | Description of identifier Vínculo: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
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Σ | 1..1 | uri | Sistema de origem do exame Exemplo General: http://www.acme.com/identifiers/patient | ||||
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Σ | 1..1 | string | Identificador do exame no sistema de origem Exemplo General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report. Padrão necessário: final | ||||
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Σ | 0..* | CodeableConcept | Service category Vínculo: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
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Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Vínculo: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
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Σ | 0..* | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
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Σ | 1..1 | uri | Identity of the terminology system | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Exame realizado Vínculo: Exame (required) | ||||
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Σ | 0..1 | string | Representation defined by the system | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 0..1 | string | Plain text representation of the concept | ||||
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Σ | 0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
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Σ | 0..1 | Clinically relevant time/time-period for report | |||||
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dateTime | |||||||
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Period | |||||||
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Σ | 1..1 | instant | Data e hora da realização do exame | ||||
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
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Σ | 2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id | ||||
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Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo | ||||
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1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor | ||||
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo | ||||
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
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0..* | Reference(Specimen) | Specimens this report is based on | |||||
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0..* | Reference(Observation) | Observations | |||||
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0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
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Σ | 0..* | BackboneElement | Key images associated with this report | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Comment about the image (e.g. explanation) | |||||
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Σ | 1..1 | Reference(Imagens do Exame) | Reference to the image source | ||||
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0..1 | string | Clinical conclusion (interpretation) of test results | |||||
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0..* | CodeableConcept | Codes for the clinical conclusion of test results Vínculo: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
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0..* | Attachment | Entire report as issued | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
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Σ | 0..1 | code | Mime type of the content, with charset etc. Vínculo: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Exemplo General: text/plain; charset=UTF-8, image/png | ||||
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Σ | 0..1 | code | Human language of the content (BCP-47) Vínculo: CommonLanguages (preferred): A human language.
Exemplo General: en-AU | ||||
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0..1 | base64Binary | Dados do(s) laudo(s) do exame | |||||
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Σ | 0..1 | url | Localização(ões) do(s) laudo(s) do exame Exemplo General: http://www.acme.com/logo-small.png | ||||
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Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
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Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
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Σ | 0..1 | string | Label to display in place of the data Exemplo General: Official Corporate Logo | ||||
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Σ | 0..1 | dateTime | Date attachment was first created | ||||
Documentação para este formato | ||||||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.basedOn.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code.coding.code | Base | required | Exame | 📦1.0.4 | este IG |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:estabelecimentoPrincipal.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:estabelecimentoExecutor.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:responsavel.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.presentedForm.contentType | Base | required | MimeType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.presentedForm.language | Base | preferred | Common Languages | 📍4.0.1 | a norma FHIR |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| 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()
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
Essa estrutura é derivada de DiagnosticReport
Resumo
Obrigatório: 5 elementos(7 aninhado obrigatoriamente elementos)
Estruturas
Esta estrutura refere-se a estas outras estruturas:
Fatias
Esta estrutura define os seguintes Slices:
Visão de diferenças
Essa estrutura é derivada de DiagnosticReport
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado |
![]() ![]() |
||||
![]() ![]() ![]() |
1..1 | uri | Sistema de origem do exame | |
![]() ![]() ![]() |
1..1 | string | Identificador do exame no sistema de origem | |
![]() ![]() |
0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |
![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() |
1..1 | code | registered | partial | preliminary | final + Padrão necessário: final | |
![]() ![]() |
||||
![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system | |
![]() ![]() ![]() ![]() |
1..1 | code | Exame realizado Vínculo: Exame (required) | |
![]() ![]() |
0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere | |
![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() |
1..1 | instant | Data e hora da realização do exame | |
![]() ![]() |
2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id | |
![]() ![]() ![]() |
1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo | |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |
![]() ![]() ![]() |
0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor | |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |
![]() ![]() ![]() |
1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo | |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |
![]() ![]() |
||||
![]() ![]() ![]() |
1..1 | Reference(Imagens do Exame) | Reference to the image source | |
![]() ![]() |
||||
![]() ![]() ![]() |
0..1 | base64Binary | Dados do(s) laudo(s) do exame | |
![]() ![]() ![]() |
0..1 | url | Localização(ões) do(s) laudo(s) do exame | |
Documentação para este formato | ||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.code.coding.code | Base | required | Exame | 📦1.0.4 | este IG |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
Visão de elementos chave
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |
![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report. Padrão necessário: final |
![]() ![]() |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Vínculo: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
![]() ![]() |
Σ | 0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere |
![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() |
Σ | 1..1 | instant | Data e hora da realização do exame |
![]() ![]() |
Σ | 2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id |
![]() ![]() ![]() |
Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |
![]() ![]() ![]() |
Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |
![]() ![]() ![]() |
Σ | 1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo |
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |
Documentação para este formato | ||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | a norma FHIR |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| 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()
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
Visão instantâneo
| Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: DataConclusaoExamePosteriorDataSolicitacaoExame, interpretacao-resultado | ||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Vínculo: CommonLanguages (preferred): A human language.
| |||||
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier for report | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
![]() ![]() ![]() |
Σ | 0..1 | CodeableConcept | Description of identifier Vínculo: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
![]() ![]() ![]() |
Σ | 1..1 | uri | Sistema de origem do exame Exemplo General: http://www.acme.com/identifiers/patient | ||||
![]() ![]() ![]() |
Σ | 1..1 | string | Identificador do exame no sistema de origem Exemplo General: 123456 | ||||
![]() ![]() ![]() |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
![]() ![]() |
0..* | Reference(Informações Sobre a Solicitação do Exame) | What was requested | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report. Padrão necessário: final | ||||
![]() ![]() |
Σ | 0..* | CodeableConcept | Service category Vínculo: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
![]() ![]() |
Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Vínculo: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | uri | Identity of the terminology system | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | code | Exame realizado Vínculo: Exame (required) | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Representation defined by the system | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() |
Σ | 0..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
![]() ![]() |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
![]() ![]() ![]() |
dateTime | |||||||
![]() ![]() ![]() |
Period | |||||||
![]() ![]() |
Σ | 1..1 | instant | Data e hora da realização do exame | ||||
![]() ![]() |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
![]() ![]() |
Σ | 2..3 | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter Fatia: Não ordenado, Fechado por value:id | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde responsável pela emissão do laudo | ||||
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de Saúde executor | ||||
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoExecutor | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Ocupacao do Profissional) | Profissional responsável pela emissão do laudo | ||||
![]() ![]() ![]() ![]() |
1..1 | string | Unique id for inter-element referencing Padrão necessário: responsavel | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
![]() ![]() |
0..* | Reference(Observation) | Observations | |||||
![]() ![]() |
0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
![]() ![]() |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
0..1 | string | Comment about the image (e.g. explanation) | |||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Imagens do Exame) | Reference to the image source | ||||
![]() ![]() |
0..1 | string | Clinical conclusion (interpretation) of test results | |||||
![]() ![]() |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Vínculo: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
![]() ![]() |
0..* | Attachment | Entire report as issued | |||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | code | Mime type of the content, with charset etc. Vínculo: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Exemplo General: text/plain; charset=UTF-8, image/png | ||||
![]() ![]() ![]() |
Σ | 0..1 | code | Human language of the content (BCP-47) Vínculo: CommonLanguages (preferred): A human language.
Exemplo General: en-AU | ||||
![]() ![]() ![]() |
0..1 | base64Binary | Dados do(s) laudo(s) do exame | |||||
![]() ![]() ![]() |
Σ | 0..1 | url | Localização(ões) do(s) laudo(s) do exame Exemplo General: http://www.acme.com/logo-small.png | ||||
![]() ![]() ![]() |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
![]() ![]() ![]() |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Label to display in place of the data Exemplo General: Official Corporate Logo | ||||
![]() ![]() ![]() |
Σ | 0..1 | dateTime | Date attachment was first created | ||||
Documentação para este formato | ||||||||
| Caminho | Estado | Utilização | Conjunto de valores | Versão | Fonte |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.basedOn.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.code.coding.code | Base | required | Exame | 📦1.0.4 | este IG |
| DiagnosticReport.subject.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:estabelecimentoPrincipal.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:estabelecimentoExecutor.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.resultsInterpreter:responsavel.type | Base | extensible | ResourceType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.presentedForm.contentType | Base | required | MimeType | 📍4.0.1 | a norma FHIR |
| DiagnosticReport.presentedForm.language | Base | preferred | Common Languages | 📍4.0.1 | a norma FHIR |
| Id | Grau | Caminho(s) | Descrição | Expressão |
| DataConclusaoExamePosteriorDataSolicitacaoExame | error | DiagnosticReport | A data de realização do exame deve ser posterior à data de solicitação do exame. |
issued > basedOn.resolve().authoredOn
|
| 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()
|
| interpretacao-resultado | error | DiagnosticReport | Impressão clínica ou confirmação diagnóstica do resultado do exame. |
conclusion.exists() xor conclusionCode.exists()
|
Essa estrutura é derivada de DiagnosticReport
Resumo
Obrigatório: 5 elementos(7 aninhado obrigatoriamente elementos)
Estruturas
Esta estrutura refere-se a estas outras estruturas:
Fatias
Esta estrutura define os seguintes Slices:
Outras representações do perfil: CSV, Excel, Schematron