Additional Resources Included in Document

Entry 1 - fullUrl = urn:uuid:5df38718-3047-4e95-8a90-413ec48e741a

Resource Composition:

Generated Narrative: Composition 5df38718-3047-4e95-8a90-413ec48e741a

Last updated: 2022-05-09 17:28:34+0000

Profile: Registro de Atendimento Clínico

status: Final

type: Registro de Atendimento Clínico

category: Atenção Hospitalar

date: 2022-05-09 15:36:40-0300

author: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/3191384

title: Registro de Atendimento Clínico

Entry 2 - fullUrl = urn:uuid:d12070e4-3461-4fa0-95a6-76fd435cb403

Resource Encounter:

Generated Narrative: Encounter d12070e4-3461-4fa0-95a6-76fd435cb403

Last updated: 2022-05-09 17:31:16+0000

Profile: Contato Assistencial

status: Finished

class: Modalidade Assistencial 04: Atenção Hospitalar

priority: Eletivo

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

participant

Ocupação: ENFERMEIRO

Identificador Nacional de Equipe: 2

type: Profissional que solicitou o Contato Assistencial

individual: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRLotacaoProfissional-1.0/815113499149874-3191384

period: 2022-04-09 15:36:40-0300 --> 2022-05-09 15:46:48-0300

reasonReference: Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

diagnosis

condition: Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

use: Diagnosis not present on admission

rank: 1

diagnosis

condition: Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

Hospitalizations

-	Extension	AdmitSource	DischargeDisposition
*		Informação ausente no modelo de origem	Óbito

Locations

-	Location
*	Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

serviceProvider: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/162338254590005

Entry 3 - fullUrl = urn:uuid:2af3c6c9-87ed-4f01-afec-ee8dc7df9951

Resource Condition:

Generated Narrative: Condition 2af3c6c9-87ed-4f01-afec-ee8dc7df9951

Last updated: 2022-05-09 17:37:55+0000

Profile: Problema / Diagnóstico

clinicalStatus: Active

category: Encounter Diagnosis

code: Varizes esofagianas sem sangramento

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

note: Varizes esofagianas sem sangramento.

Entry 4 - fullUrl = urn:uuid:1031de4c-be76-48d3-85de-75274dba036c

Resource Procedure:

Generated Narrative: Procedure 1031de4c-be76-48d3-85de-75274dba036c

Last updated: 2022-05-09 17:39:08+0000

Profile: Procedimento Realizado

Quantidade: 23

identifier: Código de Autorização/462921313170263

status: Completed

code: CONSULTA DE PROFISSIONAIS DE NIVEL SUPERIOR NA ATENÇÃO ESPECIALIZADA (EXCETO MÉDICO)

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

performed: 2022-05-09 15:36:40-0300

Performers

-	Extension	Function	Actor	OnBehalfOf
*		FISIOTERAPEUTA GERAL	Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRLotacaoProfissional-1.0/815113499149874-3191384	Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/162338254590005

Entry 5 - fullUrl = urn:uuid:c9f83c17-3081-4233-b1e4-f629c58d6813

Resource Observation:

Generated Narrative: Observation c9f83c17-3081-4233-b1e4-f629c58d6813

Last updated: 2022-05-09 17:37:55+0000

Profile: Observação Descritiva

status: Final

code: Annotation comment [Interpretation] Narrative

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

issued: 2022-05-09 17:39:08+0000

value: Varizes esofagianas sem sangramento.

Entry 6 - fullUrl = urn:uuid:6f2180c5-32aa-49cf-8b66-b2581465513c

Resource Location:

Generated Narrative: Location 6f2180c5-32aa-49cf-8b66-b2581465513c

Last updated: 2022-05-09 17:37:55+0000

Profile: Local de Atendimento

status: Active

name: Estabelecimento de saúde

mode: Kind

Entry 7 - fullUrl = urn:uuid:bd2466a4-18af-4c3b-899c-b6cccc51acff

Resource Observation:

Generated Narrative: Observation bd2466a4-18af-4c3b-899c-b6cccc51acff

Origem da Medição: Body height Measured

status: Final

code: Body height

value: 1.83 m (Details: UCUM codem = 'm')

method: Standing

Entry 8 - fullUrl = urn:uuid:84e657cc-159f-4271-b0a1-38a76e28c624

Resource Observation:

Generated Narrative: Observation 84e657cc-159f-4271-b0a1-38a76e28c624

status: Final

code: Waist Circumference at umbilicus by Tape measure

value: 135.5 cm (Details: UCUM codecm = 'cm')

Entry 9 - fullUrl = urn:uuid:5302c1a3-2190-44aa-a9a2-382d27fe9230

Resource Observation:

Generated Narrative: Observation 5302c1a3-2190-44aa-a9a2-382d27fe9230

status: Final

code: Last menstrual period start date

value: 2022-05-23

Entry 10 - fullUrl = urn:uuid:8264b367-cce0-4a76-b8d4-f9dcea39ee3d

Resource Observation:

Generated Narrative: Observation 8264b367-cce0-4a76-b8d4-f9dcea39ee3d

status: Final

code: Type of substance abused

effective: Code

value: Bebidas Alcóolicas

note: Uso ocasional de cannabis.

Entry 11 - fullUrl = urn:uuid:0509d090-3594-4f07-b32c-2a97da6a6fed

Resource Observation:

Generated Narrative: Observation 0509d090-3594-4f07-b32c-2a97da6a6fed

status: Final

code: Gestational age Estimated from last menstrual period

value: 3.5 wk (Details: UCUM codewk = 'wk')

Entry 12 - fullUrl = urn:uuid:059208f1-0083-4f81-a472-87b32140b31d

Resource Observation:

Generated Narrative: Observation 059208f1-0083-4f81-a472-87b32140b31d

status: Final

code: Head Occipital-frontal circumference

value: 45.5 cm (Details: UCUM codecm = 'cm')

Entry 13 - fullUrl = urn:uuid:98b0e992-9c95-464a-a661-6c42a4bd310c

Resource Observation:

Generated Narrative: Observation 98b0e992-9c95-464a-a661-6c42a4bd310c

Origem da Medição: Body height Stated

Roupas Usadas na Medição: Street clothes & shoes

status: Final

code: Body weight

value: 88.15 kg (Details: UCUM codekg = 'kg')

method: Standing

Entry 14 - fullUrl = urn:uuid:efcce484-7226-435f-8c7c-b1d703079444

Resource Observation:

Generated Narrative: Observation efcce484-7226-435f-8c7c-b1d703079444

status: Final

code: Systolic blood pressure

value: 0.15 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')

bodySite: Pulso esquerdo

method: Sitting

Entry 15 - fullUrl = urn:uuid:d78c1159-1473-4bef-9096-5ba98384e950

Resource Observation:

Generated Narrative: Observation d78c1159-1473-4bef-9096-5ba98384e950

status: Final

code: [#] Abortions

value: 1

Entry 16 - fullUrl = urn:uuid:32e99ca6-4e7d-4d56-8f25-612dd1c51a71

Resource Observation:

Generated Narrative: Observation 32e99ca6-4e7d-4d56-8f25-612dd1c51a71

status: Final

code: [#] Pregnancies

value: 2

Entry 17 - fullUrl = urn:uuid:19011496-44a1-4048-8e1b-558b82b1caf1

Resource Observation:

Generated Narrative: Observation 19011496-44a1-4048-8e1b-558b82b1caf1

status: Final

code: [#] Pregnancies

value: Predominante

Entry 18 - fullUrl = urn:uuid:34fe98d3-e5fc-491e-a125-c90ab2abb83a

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance 34fe98d3-e5fc-491e-a125-c90ab2abb83a

clinicalStatus: Active

verificationStatus: Confirmed

category: Food

criticality: Low Risk

code: SAT

patient: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

onset: 2022-06-01

note: Soro antitetânico

Reactions

-	Manifestation
*	Prurido

Entry 19 - fullUrl = urn:uuid:48e799d2-1087-4461-af34-8ecdd5bce316

Resource Composition:

Generated Narrative: Composition 48e799d2-1087-4461-af34-8ecdd5bce316

status: Final

type: Registro de Prescrição de Medicamento

date: 2022-03-04 14:59:51-0300

author: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/3191384

title: Registro de Prescrição de Medicamento

Entry 20 - fullUrl = urn:uuid:6d607d4c-18f4-4647-be8c-d3b40e1659bb

Resource MedicationRequest:

Generated Narrative: MedicationRequest 6d607d4c-18f4-4647-be8c-d3b40e1659bb

status: Completed

intent: Order

medication: Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

authoredOn: 2022-03-04

requester: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/3191384

recorder: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRProfissional-1.0/162338254590005

note: Medicamento necessário para tratamento da febre devido à gripe. (By Dr. Getúlio @2022-03-04)

dosageInstruction

patientInstruction: Tomar uma vez ao dia via oral.

timing: Count 1 times, 12

asNeeded: true

route: Oral

DoseAndRates

-	Type	Dose[x]
*	Cápsula	10

maxDosePerAdministration: 10

DispenseRequests

-	ValidityPeriod	Quantity
*	2022-02-24 --> 2022-03-03	10

Entry 21 - fullUrl = urn:uuid:8bea4fe3-0769-4318-b5a8-7d3a8c6f04bd

Resource Medication:

Generated Narrative: Medication 8bea4fe3-0769-4318-b5a8-7d3a8c6f04bd

code: Terminologia segundo CATMAT

form: Ampola

Entry 22 - fullUrl = urn:uuid:d2176159-0427-42da-a727-636bbb042d97

Resource CarePlan:

Generated Narrative: CarePlan d2176159-0427-42da-a727-636bbb042d97

status: Active

intent: Plan

description: Repouso pós-medicação intramuscular

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

Entry 23 - fullUrl = urn:uuid:22f0baea-50d7-429b-8767-3b07c9a8120e

Resource CarePlan:

Generated Narrative: CarePlan 22f0baea-50d7-429b-8767-3b07c9a8120e

status: Active

intent: Plan

category: Atestado Médico/Odontológico

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

addresses: Bundle: identifier = http://www.saude.gov.br/fhir/r4/NamingSystem/BRRNDS-18602#94641731211; type = document; timestamp = 2022-05-09 18:11:19+0000

activity

Details

-	Status	Scheduled[x]	Description
*	Unknown	Events: 2022-07-25 18:11:19+0000 , Count 1 times, Once	Nada digno de nota.

Entry 24 - fullUrl = urn:uuid:6f057e45-34ab-43d6-8fd5-53c1d3aa73b2

Resource Condition:

Generated Narrative: Condition 6f057e45-34ab-43d6-8fd5-53c1d3aa73b2

Last updated: 2022-05-09 17:37:55+0000

Profile: CID10 Avaliado

clinicalStatus: Active

category: Principal

code: Varizes esofagianas sem sangramento

subject: Identifier: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0/819217217061851

onset: 2023-06-16

note: Varizes esofagianas sem sangramento.