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: ExameAvaliado - Descrição detalhada

Draft as of 2026-02-07

Definições para exame-avaliado perfil.

- Elementos distintos
- Elementos
- Instantâneo

Instruções sobre como interpretar o conteúdo desta tabela podem ser encontradashere

0. DiagnosticReport
Invariantes | interpretacao-resultado: Impressão clínica ou confirmação diagnóstica do resultado do exame. (`conclusion.exists() xor conclusionCode.exists()`)
2. DiagnosticReport.code
Definição | Tipo de exame avaliado.
Curto | Exame avaliado
Vínculo | Os códigos DEVERÃO ser retirados de Exame (required to `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` )
4. DiagnosticReport.encounter
Curto | Informações do exame avaliado
Controlo | 1..?
Tipo | Reference(Consulta acompanhamento gestante)
6. DiagnosticReport.result
Curto | Resultado de referência
Controlo | 0..1
Tipo | Reference(Resultado de Exame Laboratorial Simples, Resultado de Exame Laboratorial Composto)
8. DiagnosticReport.conclusion
Definição | Impressão clínica ou confirmação diagnóstica do resultado do exame.
Curto | Interpretação do resultado
10. DiagnosticReport.conclusionCode
Definição | Sistema terminológico que representa a impressão clínica ou confirmação diagnóstica do resultado do exame.
Curto | Interpretação codificada
Vínculo | Os códigos DEVERÃO ser retirados de Conjunto de códigos CID10 e CIAP2 (required to `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` )

Instruções sobre como interpretar o conteúdo desta tabela podem ser encontradashere

0. DiagnosticReport
Definição | The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
Curto | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Comentários | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
Controlo | 0..*
É modificador | false
Resumo | false
Nomes alternativos | Report, Test, Result, Results, Labs, Laboratory
Invariantes | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) interpretacao-resultado: Impressão clínica ou confirmação diagnóstica do resultado do exame. (`conclusion.exists() xor conclusionCode.exists()`)
2. DiagnosticReport.implicitRules
Definição | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Curto | A set of rules under which this content was created
Comentários | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Controlo | 0..1
Tipo | uri
É modificador | true porque This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. DiagnosticReport.modifierExtension
Definição | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Curto | Extensions that cannot be ignored
Comentários | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Controlo | 0..*
Tipo | Extension
É modificador | true porque Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Resumo | false
Requisitos | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Nomes alternativos | extensions, user content
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. DiagnosticReport.status
Definição | The status of the diagnostic report.
Curto | registered | partial | preliminary | final +
Controlo | 1..1
Vínculo | Os códigos DEVERÃO ser retirados de DiagnosticReportStatus http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` ) The status of the diagnostic report.
Tipo | code
É modificador | true porque This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Requisitos | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. DiagnosticReport.code
Definição | Tipo de exame avaliado. A code or name that describes this diagnostic report.
Curto | Exame avaliadoName/Code for this diagnostic report
Controlo | 1..1
Vínculo | Os códigos DEVERÃO ser retirados de Exame http://hl7.org/fhir/ValueSet/report-codes (required to `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` )
Tipo | CodeableConcept
É modificador | false
Resumo | true
Nomes alternativos | Type
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. DiagnosticReport.encounter
Definição | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
Curto | Informações do exame avaliadoHealth care event when test ordered
Comentários | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Controlo | 10..1
Tipo | Reference(Consulta acompanhamento gestante, Encounter)
É modificador | false
Resumo | true
Requisitos | Links the request to the Encounter context.
Nomes alternativos | Context
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. DiagnosticReport.result
Definição | Observations that are part of this diagnostic report.
Curto | Resultado de referênciaObservations
Comentários | Observations can contain observations.
Controlo | 0..1*
Tipo | Reference(Resultado de Exame Laboratorial Simples, Resultado de Exame Laboratorial Composto, Observation)
É modificador | false
Resumo | false
Requisitos | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Nomes alternativos | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. DiagnosticReport.conclusion
Definição | Impressão clínica ou confirmação diagnóstica do resultado do exame. Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
Curto | Interpretação do resultadoClinical conclusion (interpretation) of test results
Controlo | 0..1
Tipo | string
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | false
Requisitos | Need to be able to provide a conclusion that is not lost among the basic result data.
Nomes alternativos | Report
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. DiagnosticReport.conclusionCode
Definição | Sistema terminológico que representa a impressão clínica ou confirmação diagnóstica do resultado do exame. One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.
Curto | Interpretação codificadaCodes for the clinical conclusion of test results
Controlo | 0..*
Vínculo | Os códigos DEVERÃO ser retirados de Para exemplos de códigos, ver Conjunto de códigos CID10 e CIAP2 http://hl7.org/fhir/ValueSet/clinical-findings (required to `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` )
Tipo | CodeableConcept
É modificador | false
Resumo | false
Invariantes | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Instruções sobre como interpretar o conteúdo desta tabela podem ser encontradashere

0. DiagnosticReport
Definição | The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.
Curto | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Comentários | This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
Controlo | 0..*
É modificador | false
Resumo | false
Nomes alternativos | Report, Test, Result, Results, Labs, Laboratory
Invariantes | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (`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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`) interpretacao-resultado: Impressão clínica ou confirmação diagnóstica do resultado do exame. (`conclusion.exists() xor conclusionCode.exists()`)
2. DiagnosticReport.id
Definição | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Curto | Logical id of this artifact
Comentários | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Controlo | 0..1
Tipo | id
É modificador | false
Resumo | true
4. DiagnosticReport.meta
Definição | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Curto | Metadata about the resource
Controlo | 0..1
Tipo | Meta
É modificador | false
Resumo | true
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. DiagnosticReport.implicitRules
Definição | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Curto | A set of rules under which this content was created
Comentários | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Controlo | 0..1
Tipo | uri
É modificador | true porque This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. DiagnosticReport.language
Definição | The base language in which the resource is written.
Curto | Language of the resource content
Comentários | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Controlo | 0..1
Vínculo | Os códigos DEVERÃO ser retirados de CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages` ) A human language.
Vínculos adicionais | Objetivo
AllLanguages | Vínculo máximo
Tipo | code
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | false
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. DiagnosticReport.text
Definição | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Curto | Text summary of the resource, for human interpretation
Comentários | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Controlo | 0..1
Tipo | Narrative
É modificador | false
Resumo | false
Nomes alternativos | narrative, html, xhtml, display
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. DiagnosticReport.contained
Definição | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Curto | Contained, inline Resources
Comentários | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Controlo | 0..*
Tipo | Resource
É modificador | false
Resumo | false
Nomes alternativos | inline resources, anonymous resources, contained resources
14. DiagnosticReport.extension
Definição | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Curto | Additional content defined by implementations
Comentários | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Controlo | 0..*
Tipo | Extension
É modificador | false
Resumo | false
Nomes alternativos | extensions, user content
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
16. DiagnosticReport.modifierExtension
Definição | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Curto | Extensions that cannot be ignored
Comentários | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Controlo | 0..*
Tipo | Extension
É modificador | true porque Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Resumo | false
Requisitos | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Nomes alternativos | extensions, user content
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. DiagnosticReport.identifier
Definição | Identifiers assigned to this report by the performer or other systems.
Curto | Business identifier for report
Comentários | Usually assigned by the Information System of the diagnostic service provider (filler id).
Nota | Trata-se de um identificador de empresa e não de um identificador de recurso (ver discussão)
Controlo | 0..*
Tipo | Identifier
É modificador | false
Resumo | true
Requisitos | Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.
Nomes alternativos | ReportID, Filler ID, Placer ID
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
20. DiagnosticReport.basedOn
Definição | Details concerning a service requested.
Curto | What was requested
Comentários | Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.
Controlo | 0..*
Tipo | Reference(CarePlan, ImmunizationRecommendation, MedicationRequest, NutritionOrder, ServiceRequest)
É modificador | false
Resumo | false
Requisitos | This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.
Nomes alternativos | Request
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
22. DiagnosticReport.status
Definição | The status of the diagnostic report.
Curto | registered | partial | preliminary | final +
Controlo | 1..1
Vínculo | Os códigos DEVERÃO ser retirados de DiagnosticReportStatus (required to `http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1` ) The status of the diagnostic report.
Tipo | code
É modificador | true porque This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Requisitos | Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. DiagnosticReport.category
Definição | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.
Curto | Service category
Comentários | Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.
Controlo | 0..*
Vínculo | Para exemplos de códigos, ver DiagnosticServiceSectionCodes (example to `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` ) Codes for diagnostic service sections.
Tipo | CodeableConcept
É modificador | false
Resumo | true
Nomes alternativos | Department, Sub-department, Service, Discipline
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. DiagnosticReport.code
Definição | Tipo de exame avaliado.
Curto | Exame avaliado
Controlo | 1..1
Vínculo | Os códigos DEVERÃO ser retirados de Exame (required to `https://fhir.saude.go.gov.br/r4/exame/ValueSet/exame` )
Tipo | CodeableConcept
É modificador | false
Resumo | true
Nomes alternativos | Type
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. DiagnosticReport.subject
Definição | The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.
Curto | The subject of the report - usually, but not always, the patient
Controlo | 0..1
Tipo | Reference(Patient, Group, Device, Location)
É modificador | false
Resumo | true
Requisitos | SHALL know the subject context.
Nomes alternativos | Patient
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. DiagnosticReport.encounter
Definição | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.
Curto | Informações do exame avaliado
Comentários | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
Controlo | 1..1
Tipo | Reference(Consulta acompanhamento gestante)
É modificador | false
Resumo | true
Requisitos | Links the request to the Encounter context.
Nomes alternativos | Context
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. DiagnosticReport.effective[x]
Definição | The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.
Curto | Clinically relevant time/time-period for report
Comentários | If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
Controlo | 0..1
Tipo | Escolha de: dateTime, Period
[x] Nota | VerEscolha de tipos de dadospara mais informações sobre como utilizar [x]
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Requisitos | Need to know where in the patient history to file/present this report.
Nomes alternativos | Observation time, Effective Time, Occurrence
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. DiagnosticReport.issued
Definição | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.
Curto | DateTime this version was made
Comentários | May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
Controlo | 0..1
Tipo | instant
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | true
Requisitos | Clinicians need to be able to check the date that the report was released.
Nomes alternativos | Date published, Date Issued, Date Verified
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. DiagnosticReport.performer
Definição | The diagnostic service that is responsible for issuing the report.
Curto | Responsible Diagnostic Service
Comentários | This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
Controlo | 0..*
Tipo | Reference(Practitioner, PractitionerRole, Organization, CareTeam)
É modificador | false
Resumo | true
Requisitos | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Nomes alternativos | Laboratory, Service, Practitioner, Department, Company, Authorized by, Director
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. DiagnosticReport.resultsInterpreter
Definição | The practitioner or organization that is responsible for the report's conclusions and interpretations.
Curto | Primary result interpreter
Comentários | Might not be the same entity that takes responsibility for the clinical report.
Controlo | 0..*
Tipo | Reference(Practitioner, PractitionerRole, Organization, CareTeam)
É modificador | false
Resumo | true
Requisitos | Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.
Nomes alternativos | Analyzed by, Reported by
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. DiagnosticReport.specimen
Definição | Details about the specimens on which this diagnostic report is based.
Curto | Specimens this report is based on
Comentários | If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
Controlo | 0..*
Tipo | Reference(Specimen)
É modificador | false
Resumo | false
Requisitos | Need to be able to report information about the collected specimens on which the report is based.
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. DiagnosticReport.result
Definição | Observations that are part of this diagnostic report.
Curto | Resultado de referência
Comentários | Observations can contain observations.
Controlo | 0..1
Tipo | Reference(Resultado de Exame Laboratorial Simples, Resultado de Exame Laboratorial Composto)
É modificador | false
Resumo | false
Requisitos | Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.
Nomes alternativos | Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
44. DiagnosticReport.imagingStudy
Definição | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.
Curto | Reference to full details of imaging associated with the diagnostic report
Comentários | ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.
Controlo | 0..*
Tipo | Reference(ImagingStudy)
É modificador | false
Resumo | false
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
46. DiagnosticReport.media
Definição | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).
Curto | Key images associated with this report
Controlo | 0..*
Tipo | BackboneElement
É modificador | false
Resumo | true
Requisitos | Many diagnostic services include images in the report as part of their service.
Nomes alternativos | DICOM, Slides, Scans
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
48. DiagnosticReport.media.id
Definição | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Curto | Unique id for inter-element referencing
Controlo | 0..1
Tipo | string
É modificador | false
Formato XML | No formato XML, esta propriedade é representada como um atributo.
Resumo | false
50. DiagnosticReport.media.extension
Definição | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Curto | Additional content defined by implementations
Comentários | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Controlo | 0..*
Tipo | Extension
É modificador | false
Resumo | false
Nomes alternativos | extensions, user content
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
52. DiagnosticReport.media.modifierExtension
Definição | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Curto | Extensions that cannot be ignored even if unrecognized
Comentários | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Controlo | 0..*
Tipo | Extension
É modificador | true porque Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Resumo | true
Requisitos | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Nomes alternativos | extensions, user content, modifiers
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
54. DiagnosticReport.media.comment
Definição | A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.
Curto | Comment about the image (e.g. explanation)
Comentários | The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.
Controlo | 0..1
Tipo | string
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | false
Requisitos | The provider of the report should make a comment about each image included in the report.
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. DiagnosticReport.media.link
Definição | Reference to the image source.
Curto | Reference to the image source
Controlo | 1..1
Tipo | Reference(Media)
É modificador | false
Resumo | true
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. DiagnosticReport.conclusion
Definição | Impressão clínica ou confirmação diagnóstica do resultado do exame.
Curto | Interpretação do resultado
Controlo | 0..1
Tipo | string
É modificador | false
Valor primitivo | Este elemento primitivo pode estar presente, ausente ou ser substituído por uma extensão
Resumo | false
Requisitos | Need to be able to provide a conclusion that is not lost among the basic result data.
Nomes alternativos | Report
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. DiagnosticReport.conclusionCode
Definição | Sistema terminológico que representa a impressão clínica ou confirmação diagnóstica do resultado do exame.
Curto | Interpretação codificada
Controlo | 0..*
Vínculo | Os códigos DEVERÃO ser retirados de Conjunto de códigos CID10 e CIAP2 (required to `https://fhir.saude.go.gov.br/r4/saude-mulher/ValueSet/cid10-ciap2` )
Tipo | CodeableConcept
É modificador | false
Resumo | false
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. DiagnosticReport.presentedForm
Definição | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.
Curto | Entire report as issued
Comentários | "application/pdf" is recommended as the most reliable and interoperable in this context.
Controlo | 0..*
Tipo | Attachment
É modificador | false
Resumo | false
Requisitos | Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.
Invariantes | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)