Guia de Implementação da SES GO - EXAME
1.0.0 - draft

Guia de Implementação da SES GO - EXAME - Downloaded Version 1.0.0 See the Directory of published versions

## Perfil: Resultado de Exame Laboratorial Simples

URL oficial: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/exame-simples | Versão: 1.0.0
Draft as of 2025-12-05 | Nome para computador: ExameSimples

Resultado de Exame Laboratorial Simples

Usos:

- Refere a este Perfil: Resultado de Exame Laboratorial Composto
- Exemplos para este Perfil: Observation/hemacias, Observation/hematocrito and Observation/hemoglobina

You can also check for usages in the FHIR IG Statistics

### Representações do perfil

Descrição de perfis, diferenças, instantâneo, e como apresentações diferentes funcionam.

- Diferenças
- Elementos chave
- Detalhes
- Estatísticas/Referencias
- Tudo

Essa estrutura é derivada de Observation

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: RN03-Exame, RN04-Exame
extension |  | 0..0 |  |
modifierExtension |  | 0..0 |  |
identifier |  | 0..0 |  |
basedOn |  | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
partOf |  | 0..0 |  |
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code |  | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject |  | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
identifier | C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
system |  | 1..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
focus |  | 0..0 |  |
encounter |  | 0..0 |  |
effective[x] |  | 0..0 |  |
issued |  | 1..1 | instant | Data e hora do resultado
Fatias para performer |  | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
identifier |  | 1..1 | Identifier | Logical reference, when literal reference is not known
system |  | 1..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
performer:estabelecimentoPrincipal |  | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
performer:estabelecimentoApoio |  | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
performer:responsavelTecnico |  | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
extension |  | 1..* | Extension | Extension
Fatias para extension |  |  |  | Conteúdo/regras para todas as fatias
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
performer:responsavelResultado |  | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
extension |  | 1..* | Extension | Extension
Fatias para extension |  |  |  | Conteúdo/regras para todas as fatias
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
Fatias para value[x] |  | 1..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
value[x]:valueCodeableConcept |  | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString |  | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity |  | 0..1 | Quantity | Resultado do exame quantitativo
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
dataAbsentReason |  | 0..0 |  |
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado
note |  | 0..* | Annotation | Notas sobre o resultado
bodySite |  | 0..0 |  |
method |  | 0..1 | CodeableConcept | Método de análise
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
device |  | 0..0 |  |
referenceRange |  |  |  |
low |  | 0..1 | SimpleQuantity | Valor inferior
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
high |  | 0..1 | SimpleQuantity | Valor superior
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
type |  | 0..1 | CodeableConcept | Significado do intervalo
appliesTo |  | 0..* | CodeableConcept | População-alvo
age |  | 0..1 | Range | Idade-alvo
text |  | 0..1 | string | Valores de referência descritivos
hasMember |  | 0..0 |  |
derivedFrom |  | 0..0 |  |
component |  | 0..0 |  |
Documentação para este formato

#### Terminologia Ligações (Diferencial)

Caminho | Conformidade | Conjunto de valores | URI
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, RN03-Exame, RN04-Exame
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
basedOn | Σ | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code | Σ | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject | Σ | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
identifier | Σ C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
issued | Σ | 1..1 | instant | Data e hora do resultado
Fatias para performer | Σ | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:estabelecimentoPrincipal | Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:estabelecimentoApoio | Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:responsavelTecnico | Σ | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:responsavelResultado | Σ | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
Fatias para value[x] | Σ C | 1..1 |  | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
value[x]:valueCodeableConcept | Σ C | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString | Σ C | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity | Σ C | 0..1 | Quantity | Resultado do exame quantitativo
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Vínculo: QuantityComparator (required): How the Quantity should be understood and represented.
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado Vínculo: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Notas sobre o resultado
method |  | 0..1 | CodeableConcept | Método de análise Vínculo: ObservationMethods (example): Methods for simple observations.
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From a norma FHIR
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.subject.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelResultado.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG
Observation.value[x]:valueQuantity.comparator | required | QuantityComparator `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` From a norma FHIR
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From a norma FHIR
Observation.component.code | example | LOINCCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` From a norma FHIR

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | 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() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, RN03-Exame, RN04-Exame
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 adicionais | Objetivo
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
basedOn | Σ | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code | Σ | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject | Σ | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
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
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
issued | Σ | 1..1 | instant | Data e hora do resultado
Fatias para performer | Σ | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
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
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:estabelecimentoPrincipal | Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
extension |  | 0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:estabelecimentoApoio | Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
extension |  | 0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:responsavelTecnico | Σ | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:responsavelResultado | Σ | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
Fatias para value[x] | Σ C | 1..1 |  | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
value[x]:valueCodeableConcept | Σ C | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString | Σ C | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity | Σ C | 0..1 | Quantity | Resultado do exame quantitativo
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Vínculo: QuantityComparator (required): How the Quantity should be understood and represented.
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado Vínculo: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Notas sobre o resultado
method |  | 0..1 | CodeableConcept | Método de análise Vínculo: ObservationMethods (example): Methods for simple observations.
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
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
low | C | 0..1 | SimpleQuantity | Valor inferior
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
high | C | 0..1 | SimpleQuantity | Valor superior
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
type |  | 0..1 | CodeableConcept | Significado do intervalo Vínculo: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | População-alvo Vínculo: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Idade-alvo
text |  | 0..1 | string | Valores de referência descritivos
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From a norma FHIR
Vínculos adicionais | Objetivo
AllLanguages | Vínculo máximo
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From a norma FHIR
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.subject.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.subject.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:estabelecimentoApoio.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:responsavelTecnico.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:responsavelResultado.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:responsavelResultado.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelResultado.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG
Observation.value[x]:valueQuantity.comparator | required | QuantityComparator `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` From a norma FHIR
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From a norma FHIR
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From a norma FHIR
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` From a norma FHIR
Observation.component.code | example | LOINCCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` From a norma FHIR
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From a norma FHIR
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | 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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Essa estrutura é derivada de Observation

Resumo

Obrigatório: 18 elementos
Proibido: 13 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

- Informações Sobre a Solicitação do Exame (https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/suspeita-diagnostica-investigada)
- Indivíduo (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/individuo)
- Estabelecimento de Saúde (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/estabelecimento-saude)
- Profissional (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/profissional)
- Amostra para Exame Laboratorial (https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/amostra)

Extensões

Esta estrutura refere-se a estas extensões:

- https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional

Fatias

Esta estrutura define os seguintes Slices:

- The element 1 is sliced based on the value of Observation.performer (Closed)
- The element 1 is sliced based on the value of Observation.value[x]

Visão de diferenças

Essa estrutura é derivada de Observation

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: RN03-Exame, RN04-Exame
extension |  | 0..0 |  |
modifierExtension |  | 0..0 |  |
identifier |  | 0..0 |  |
basedOn |  | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
partOf |  | 0..0 |  |
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code |  | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject |  | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
identifier | C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
system |  | 1..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
focus |  | 0..0 |  |
encounter |  | 0..0 |  |
effective[x] |  | 0..0 |  |
issued |  | 1..1 | instant | Data e hora do resultado
Fatias para performer |  | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
identifier |  | 1..1 | Identifier | Logical reference, when literal reference is not known
system |  | 1..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
performer:estabelecimentoPrincipal |  | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
performer:estabelecimentoApoio |  | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
performer:responsavelTecnico |  | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
extension |  | 1..* | Extension | Extension
Fatias para extension |  |  |  | Conteúdo/regras para todas as fatias
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
performer:responsavelResultado |  | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
extension |  | 1..* | Extension | Extension
Fatias para extension |  |  |  | Conteúdo/regras para todas as fatias
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
Fatias para value[x] |  | 1..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
value[x]:valueCodeableConcept |  | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString |  | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity |  | 0..1 | Quantity | Resultado do exame quantitativo
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
dataAbsentReason |  | 0..0 |  |
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado
note |  | 0..* | Annotation | Notas sobre o resultado
bodySite |  | 0..0 |  |
method |  | 0..1 | CodeableConcept | Método de análise
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
device |  | 0..0 |  |
referenceRange |  |  |  |
low |  | 0..1 | SimpleQuantity | Valor inferior
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
high |  | 0..1 | SimpleQuantity | Valor superior
system |  | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
type |  | 0..1 | CodeableConcept | Significado do intervalo
appliesTo |  | 0..* | CodeableConcept | População-alvo
age |  | 0..1 | Range | Idade-alvo
text |  | 0..1 | string | Valores de referência descritivos
hasMember |  | 0..0 |  |
derivedFrom |  | 0..0 |  |
component |  | 0..0 |  |
Documentação para este formato

#### Terminologia Ligações (Diferencial)

Caminho | Conformidade | Conjunto de valores | URI
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |

Visão de elementos chave

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, RN03-Exame, RN04-Exame
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
basedOn | Σ | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code | Σ | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject | Σ | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
identifier | Σ C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
issued | Σ | 1..1 | instant | Data e hora do resultado
Fatias para performer | Σ | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:estabelecimentoPrincipal | Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:estabelecimentoApoio | Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:responsavelTecnico | Σ | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
performer:responsavelResultado | Σ | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
Fatias para value[x] | Σ C | 1..1 |  | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
value[x]:valueCodeableConcept | Σ C | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString | Σ C | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity | Σ C | 0..1 | Quantity | Resultado do exame quantitativo
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Vínculo: QuantityComparator (required): How the Quantity should be understood and represented.
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado Vínculo: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Notas sobre o resultado
method |  | 0..1 | CodeableConcept | Método de análise Vínculo: ObservationMethods (example): Methods for simple observations.
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From a norma FHIR
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.subject.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelResultado.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG
Observation.value[x]:valueQuantity.comparator | required | QuantityComparator `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` From a norma FHIR
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From a norma FHIR
Observation.component.code | example | LOINCCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` From a norma FHIR

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | 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() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Visão instantâneo

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7, RN03-Exame, RN04-Exame
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 adicionais | Objetivo
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
basedOn | Σ | 0..* | Reference(Informações Sobre a Solicitação do Exame) | Suspeita diagnóstica investigada
status | ?!Σ | 1..1 | code | registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
category |  | 1..1 | CodeableConcept | Categoria do exame Vínculo: Subgrupos da Tabela SUS (required)
code | Σ | 1..1 | CodeableConcept | Exame Vínculo: Exame (required)
subject | Σ | 1..1 | Reference(Indivíduo) | Cidadão(ã) ao qual o exame se refere
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
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ C | 1..1 | Identifier | Logical reference, when literal reference is not known Constraints: CPFouCNS
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
issued | Σ | 1..1 | instant | Data e hora do resultado
Fatias para performer | Σ | 3..4 | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation Fatia: Não ordenado, Fechado por value:$this.id
performer:Todas as fatias |  |  |  | Conteúdo/regras para todas as fatias
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
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:estabelecimentoPrincipal | Σ | 1..1 | Reference(Estabelecimento de Saúde) | Estabelecimento principal
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoPrincipal
extension |  | 0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:estabelecimentoApoio | Σ | 0..1 | Reference(Estabelecimento de Saúde) | Estabelecimento de apoio ou referência - executor
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: estabelecimentoApoio
extension |  | 0..* | Extension | Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:responsavelTecnico | Σ | 1..1 | Reference(Profissional) | Identificação do(a) responsável técnico(a)
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelTecnico
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
performer:responsavelResultado | Σ | 1..1 | Reference(Profissional) | Responsável pelo resultado
id |  | 0..1 | string | Unique id for inter-element referencing Padrão necessário: responsavelResultado
Fatias para extension |  | 1..* | Extension | Extension Fatia: Não ordenado, Aberto por value:url
extension:conselhoProfissional |  | 1..1 | (Complexo) | Conselho Profissional URL: https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
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
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Vínculo: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 1..1 | uri | The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Exemplo General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
Fatias para value[x] | Σ C | 1..1 |  | Resultado do exame Fatia: Não ordenado, Aberto por type:$this
valueQuantity |  |  | Quantity |
valueCodeableConcept |  |  | CodeableConcept |
valueString |  |  | string |
valueBoolean |  |  | boolean |
valueInteger |  |  | integer |
valueRange |  |  | Range |
valueRatio |  |  | Ratio |
valueSampledData |  |  | SampledData |
valueTime |  |  | time |
valueDateTime |  |  | dateTime |
valuePeriod |  |  | Period |
value[x]:valueCodeableConcept | Σ C | 0..1 | CodeableConcept | Resultado do exame qualitativo - estruturado Vínculo: Resultado Qualitativo Exame (required)
value[x]:valueString | Σ C | 0..1 | string | Resultado do exame qualitativo - descritivo
value[x]:valueQuantity | Σ C | 0..1 | Quantity | Resultado do exame quantitativo
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
comparator | ?!Σ | 0..1 | code | < | <= | >= | > - how to understand the value Vínculo: QuantityComparator (required): How the Quantity should be understood and represented.
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
interpretation |  | 0..* | CodeableConcept | Interpretação do exame estruturado Vínculo: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note |  | 0..* | Annotation | Notas sobre o resultado
method |  | 0..1 | CodeableConcept | Método de análise Vínculo: ObservationMethods (example): Methods for simple observations.
specimen | C | 1..1 | Reference(Amostra para Exame Laboratorial) | Amostra biológica Constraints: ReferenceContained
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation Constraints: obs-3
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
low | C | 0..1 | SimpleQuantity | Valor inferior
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
high | C | 0..1 | SimpleQuantity | Valor superior
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
value | Σ | 0..1 | decimal | Numerical value (with implicit precision)
unit | Σ | 0..1 | string | Unit representation
system | Σ C | 0..1 | uri | System that defines coded unit form Padrão necessário: http://unitsofmeasure.org
code | Σ | 0..1 | code | Coded form of the unit
type |  | 0..1 | CodeableConcept | Significado do intervalo Vínculo: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo |  | 0..* | CodeableConcept | População-alvo Vínculo: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age |  | 0..1 | Range | Idade-alvo
text |  | 0..1 | string | Valores de referência descritivos
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
Observation.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From a norma FHIR
Vínculos adicionais | Objetivo
AllLanguages | Vínculo máximo
Observation.status | required | ObservationStatus `http://hl7.org/fhir/ValueSet/observation-status|4.0.1` From a norma FHIR
Observation.category | required | Subgrupos da Tabela SUS `http://www.saude.gov.br/fhir/r4/ValueSet/BRSubgrupoTabelaSUS`
Observation.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` From este IG
Observation.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.subject.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.subject.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoPrincipal.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:estabelecimentoApoio.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:estabelecimentoApoio.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:responsavelTecnico.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelTecnico.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.performer:responsavelResultado.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From a norma FHIR
Observation.performer:responsavelResultado.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From a norma FHIR
Observation.performer:responsavelResultado.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From a norma FHIR
Observation.value[x]:valueCodeableConcept | required | ResultadoQualitativoExame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/resultado-qualitativo-exame` From este IG
Observation.value[x]:valueQuantity.comparator | required | QuantityComparator `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` From a norma FHIR
Observation.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR
Observation.method | example | ObservationMethods `http://hl7.org/fhir/ValueSet/observation-methods` From a norma FHIR
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes `http://hl7.org/fhir/ValueSet/referencerange-meaning` From a norma FHIR
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes `http://hl7.org/fhir/ValueSet/referencerange-appliesto` From a norma FHIR
Observation.component.code | example | LOINCCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/observation-codes` From a norma FHIR
Observation.component.dataAbsentReason | extensible | DataAbsentReason `http://hl7.org/fhir/ValueSet/data-absent-reason` From a norma FHIR
Observation.component.interpretation | extensible | ObservationInterpretationCodes `http://hl7.org/fhir/ValueSet/observation-interpretation` From a norma FHIR

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
CPFouCNS | error | Observation.subject.identifier | O sistema de identificação do indivíduo deve ser ou CPF ou CNS : system = 'https://fhir.saude.go.gov.br/sid/cpf' or system = 'https://fhir.saude.go.gov.br/sid/cns' |
RN03-Exame | warning | Observation | Se a terminologia utilizada para representar o exame for Tabela SUS, TUSS ou CBHPM, o elemento method deve ser fornecido. O exame realizado deve utilizar as terminologias (Tabela SUS, TUSS ou CBHPM) para representar o método analítico utilizado para determinação do resultado. : code.coding.where(system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRTabelaSUS' or system = 'http://www.saude.gov.br/fhir/r4/CodeSystem/BRCBHPMTUSS').exists() implies method.exists() |
RN04-Exame | warning | Observation | Se o resultado for quantitativo, é obrigatório enviar os valores de referência (referenceRange), sejam eles estruturados ou não estruturados. O laudo deve conter os valores de referência sobre o resultado quantitativo sendo eles estruturados ou não estruturados. : (value is Quantity) implies referenceRange.exists() |
ReferenceContained | error | Observation.specimen | Referência deve ser um recurso contido : reference.startsWith('#') |
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Observation | 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 | Observation | 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 | Observation | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Observation | 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() |
obs-3 | error | Observation.referenceRange | Must have at least a low or a high or text : low.exists() or high.exists() or text.exists() |
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty() |
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty() |

Essa estrutura é derivada de Observation

Resumo

Obrigatório: 18 elementos
Proibido: 13 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

- Informações Sobre a Solicitação do Exame (https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/suspeita-diagnostica-investigada)
- Indivíduo (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/individuo)
- Estabelecimento de Saúde (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/estabelecimento-saude)
- Profissional (https://fhir.saude.go.gov.br/r4/core/StructureDefinition/profissional)
- Amostra para Exame Laboratorial (https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/amostra)

Extensões

Esta estrutura refere-se a estas extensões:

- https://fhir.saude.go.gov.br/r4/exame/StructureDefinition/conselho-profissional

Fatias

Esta estrutura define os seguintes Slices:

- The element 1 is sliced based on the value of Observation.performer (Closed)
- The element 1 is sliced based on the value of Observation.value[x]

Outras representações do perfil: CSV, Excel, Schematron