Guia de Implementação da SES GO - Saúde da Mulher
1.0.1 - draft BR

Guia de Implementação da SES GO - Saúde da Mulher - Downloaded Version 1.0.1 See the Directory of published versions

## Perfil: Exame Avaliado

URL oficial: https://fhir.saude.go.gov.br/r4/saude-mulher/StructureDefinition/exame-avaliado | Versão: 1.0.1
Draft as of 2026-02-07 | Domínio: | Nome para computador: ExameAvaliado

Usos:

- Exemplos para este Perfil: DiagnosticReport/ExameAvaliadoExemplo

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 DiagnosticReport

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
code |  | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
encounter |  | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
Documentação para este formato

#### Terminologia Ligações (Diferencial)

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report.
code | Σ | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
encounter | Σ | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From a norma FHIR
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
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
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report.
category | Σ | 0..* | CodeableConcept | Service category Vínculo: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code | Σ | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
encounter | Σ | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From a norma FHIR
Vínculos adicionais | Objetivo
AllLanguages | Vínculo máximo
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From a norma FHIR
DiagnosticReport.category | example | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From a norma FHIR
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: 1 elemento

Estruturas

Esta estrutura refere-se a estas outras estruturas:

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

Visão de diferenças

Essa estrutura é derivada de DiagnosticReport

Nome | Bandeiras | Card. | Tipo | Descrição e condicionalismos Filter: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
code |  | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
encounter |  | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
Documentação para este formato

#### Terminologia Ligações (Diferencial)

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report.
code | Σ | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
encounter | Σ | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From a norma FHIR
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: Condicionantes Obrigações Vínculos
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: interpretacao-resultado
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
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Vínculo: DiagnosticReportStatus (required): The status of the diagnostic report.
category | Σ | 0..* | CodeableConcept | Service category Vínculo: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code | Σ | 1..1 | CodeableConcept | Exame avaliado Vínculo: Exame (required)
subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient
encounter | Σ | 1..1 | Reference(Consulta acompanhamento gestante) | Informações do exame avaliado
effective[x] | Σ | 0..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on
result |  | 0..1 | Reference(Resultado de Exame Laboratorial Simples | Resultado de Exame Laboratorial Composto) | Resultado de referência
imagingStudy |  | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report
media | Σ | 0..* | BackboneElement | Key images associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
comment |  | 0..1 | string | Comment about the image (e.g. explanation)
link | Σ | 1..1 | Reference(Media) | Reference to the image source
conclusion |  | 0..1 | string | Interpretação do resultado
conclusionCode |  | 0..* | CodeableConcept | Interpretação codificada Vínculo: Conjunto de códigos CID10 e CIAP2 (required)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentação para este formato

#### Terminologia Ligações

Caminho | Conformidade | Conjunto de valores | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From a norma FHIR
Vínculos adicionais | Objetivo
AllLanguages | Vínculo máximo
DiagnosticReport.status | required | DiagnosticReportStatus `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` From a norma FHIR
DiagnosticReport.category | example | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From a norma FHIR
DiagnosticReport.code | required | Exame `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame`
DiagnosticReport.conclusionCode | required | CID10CIAP2 `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` From este IG

#### Restrições

Id | Grau | Caminho(s) | Detalhes | Requisitos
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: 1 elemento

Estruturas

Esta estrutura refere-se a estas outras estruturas:

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

Outras representações do perfil: CSV, Excel, Schematron