Guia de Implementação do Registro de Atendimento Clínico (RAC) da RNDS
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Guia de Implementação do Registro de Atendimento Clínico (RAC) da RNDS - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: Bundle de Exemplo do Registro de Atendimento Clínico (RAC) - Paciente Identificado

Generated Narrative: Composition

Resource Composition "5df38718-3047-4e95-8a90-413ec48e741a" Updated "2022-05-09 17:28:34+0000"

Profile: Registro de Atendimento Clínico

status: FINAL

type: Registro de Atendimento Clínico (Tipo de Documento#RAC)

category: Atenção Hospitalar (Modalidade Assistencial#04)

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

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

title: Registro de Atendimento Clínico

Additional Document Content

2. urn:uuid:d12070e4-3461-4fa0-95a6-76fd435cb403 (Encounter/d12070e4-3461-4fa0-95a6-76fd435cb403)

Not done yet

3. urn:uuid:2af3c6c9-87ed-4f01-afec-ee8dc7df9951 (Condition/2af3c6c9-87ed-4f01-afec-ee8dc7df9951)

Generated Narrative: Condition

Resource Condition "2af3c6c9-87ed-4f01-afec-ee8dc7df9951" Updated "2022-05-09 17:37:55+0000"

Profile: Problema / Diagnóstico

clinicalStatus: Active (Condition Clinical Status Codes#active)

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: Varizes esofagianas sem sangramento (Classificação Internacional de Doenças - Décima Revisão - CID-10#I859)

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

note: Varizes esofagianas sem sangramento.

4. urn:uuid:1031de4c-be76-48d3-85de-75274dba036c (Procedure/1031de4c-be76-48d3-85de-75274dba036c)

Generated Narrative: Procedure

Resource Procedure "1031de4c-be76-48d3-85de-75274dba036c" 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) (Tabela de procedimentos, medicamentos e OPM do SUS#0301010048)

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

Performers

-ExtensionFunctionActorOnBehalfOf
*FISIOTERAPEUTA GERAL (Classificação Brasileira de Ocupações - CBO#223605)http://www.saude.gov.br/fhir/r4/StructureDefinition/BRLotacaoProfissional-1.0/815113499149874-3191384http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0/162338254590005

5. urn:uuid:c9f83c17-3081-4233-b1e4-f629c58d6813 (Observation/c9f83c17-3081-4233-b1e4-f629c58d6813)

Generated Narrative: Observation

Resource Observation "c9f83c17-3081-4233-b1e4-f629c58d6813" Updated "2022-05-09 17:37:55+0000"

Profile: Observação Descritiva

status: FINAL

code: Annotation comment Imp (LOINC#48767-8)

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

issued: 9 de mai. de 2022 14:39:08

value: Varizes esofagianas sem sangramento.

6. urn:uuid:6f2180c5-32aa-49cf-8b66-b2581465513c (Location/6f2180c5-32aa-49cf-8b66-b2581465513c)

Generated Narrative: Location

Resource Location "6f2180c5-32aa-49cf-8b66-b2581465513c" Updated "2022-05-09 17:37:55+0000"

Profile: Local de Atendimento

status: ACTIVE

name: Estabelecimento de saúde

mode: KIND

7. urn:uuid:bd2466a4-18af-4c3b-899c-b6cccc51acff (Observation/bd2466a4-18af-4c3b-899c-b6cccc51acff)

Generated Narrative: Observation

Resource Observation "bd2466a4-18af-4c3b-899c-b6cccc51acff"

Profile: Medida Observada

Origem da Medição: Body height Measured (LOINC#3137-7)

status: FINAL

code: Body height (LOINC#8302-2)

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

method: Standing (LOINC#LA11870-5)

8. urn:uuid:84e657cc-159f-4271-b0a1-38a76e28c624 (Observation/84e657cc-159f-4271-b0a1-38a76e28c624)

Generated Narrative: Observation

Resource Observation "84e657cc-159f-4271-b0a1-38a76e28c624"

Profile: Medida Observada

status: FINAL

code: Circumf.at umbilicus by Tape measure (LOINC#8280-0)

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

9. urn:uuid:5302c1a3-2190-44aa-a9a2-382d27fe9230 (Observation/5302c1a3-2190-44aa-a9a2-382d27fe9230)

Generated Narrative: Observation

Resource Observation "5302c1a3-2190-44aa-a9a2-382d27fe9230"

Profile: Medida Observada

status: FINAL

code: LMP Start date (LOINC#8665-2)

value: 2022-05-23

10. urn:uuid:8264b367-cce0-4a76-b8d4-f9dcea39ee3d (Observation/8264b367-cce0-4a76-b8d4-f9dcea39ee3d)

Generated Narrative: Observation

Resource Observation "8264b367-cce0-4a76-b8d4-f9dcea39ee3d"

Profile: Medida Observada

status: FINAL

code: Type of substance abused (LOINC#56832-9)

effective: Code: 1 ou 2 vezes

value: Bebidas Alcóolicas (Tipo de Substância em Uso#alcool)

note: Uso ocasional de cannabis.

11. urn:uuid:0509d090-3594-4f07-b32c-2a97da6a6fed (Observation/0509d090-3594-4f07-b32c-2a97da6a6fed)

Generated Narrative: Observation

Resource Observation "0509d090-3594-4f07-b32c-2a97da6a6fed"

Profile: Medida Observada

status: FINAL

code: GA Est from LMP (LOINC#11885-1)

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

12. urn:uuid:059208f1-0083-4f81-a472-87b32140b31d (Observation/059208f1-0083-4f81-a472-87b32140b31d)

Generated Narrative: Observation

Resource Observation "059208f1-0083-4f81-a472-87b32140b31d"

Profile: Medida Observada

status: FINAL

code: Head Circumf OFC (LOINC#9843-4)

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

13. urn:uuid:98b0e992-9c95-464a-a661-6c42a4bd310c (Observation/98b0e992-9c95-464a-a661-6c42a4bd310c)

Generated Narrative: Observation

Resource Observation "98b0e992-9c95-464a-a661-6c42a4bd310c"

Profile: Medida Observada

Origem da Medição: Body height Stated (LOINC#3138-5)

Roupas Usadas na Medição: Street clothes & shoes (LOINC#LA11873-9)

status: FINAL

code: Weight (LOINC#29463-7)

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

method: Standing (LOINC#LA11870-5)

14. urn:uuid:efcce484-7226-435f-8c7c-b1d703079444 (Observation/efcce484-7226-435f-8c7c-b1d703079444)

Generated Narrative: Observation

Resource Observation "efcce484-7226-435f-8c7c-b1d703079444"

Profile: Medida Observada

status: FINAL

code: BP sys (LOINC#8480-6)

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

bodySite: Pulso esquerdo (Local de Aferição#6)

method: Sitting (LOINC#LA11868-9)

15. urn:uuid:d78c1159-1473-4bef-9096-5ba98384e950 (Observation/d78c1159-1473-4bef-9096-5ba98384e950)

Generated Narrative: Observation

Resource Observation "d78c1159-1473-4bef-9096-5ba98384e950"

Profile: Medida Observada

status: FINAL

code: Abortions (LOINC#11612-9)

value: 1

16. urn:uuid:32e99ca6-4e7d-4d56-8f25-612dd1c51a71 (Observation/32e99ca6-4e7d-4d56-8f25-612dd1c51a71)

Generated Narrative: Observation

Resource Observation "32e99ca6-4e7d-4d56-8f25-612dd1c51a71"

Profile: Medida Observada

status: FINAL

code: Pregnancies (LOINC#11996-6)

value: 2

17. urn:uuid:19011496-44a1-4048-8e1b-558b82b1caf1 (Observation/19011496-44a1-4048-8e1b-558b82b1caf1)

Generated Narrative: Observation

Resource Observation "19011496-44a1-4048-8e1b-558b82b1caf1"

Profile: Medida Observada

status: FINAL

code: Pregnancies (LOINC#11996-6)

value: Predominante (Tipo de Aleitamento Materno#predominante)

18. urn:uuid:34fe98d3-e5fc-491e-a125-c90ab2abb83a (AllergyIntolerance/34fe98d3-e5fc-491e-a125-c90ab2abb83a)

Generated Narrative: AllergyIntolerance

Resource AllergyIntolerance "34fe98d3-e5fc-491e-a125-c90ab2abb83a"

Profile: Alergia ou Reação Adversa

clinicalStatus: Active (AllergyIntolerance Clinical Status Codes#active)

verificationStatus: Confirmed (AllergyIntolerance Verification Status#confirmed)

category: FOOD

criticality: LOW

code: SAT (Imunobiológico#2)

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

onset: 2022-06-01

note: Soro antitetânico

Reactions

-Manifestation
*Prurido (Medical Dictionary for Regulatory Activities (MedDRA)#10037087)

19. urn:uuid:48e799d2-1087-4461-af34-8ecdd5bce316 (Composition/48e799d2-1087-4461-af34-8ecdd5bce316)

Generated Narrative: Composition

Resource Composition "48e799d2-1087-4461-af34-8ecdd5bce316"

Profile: Registro de Prescrição de Medicamento

status: FINAL

type: Registro de Prescrição de Medicamento (Tipo de Documento#RPM)

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

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

title: Registro de Prescrição de Medicamento

20. urn:uuid:6d607d4c-18f4-4647-be8c-d3b40e1659bb (MedicationRequest/6d607d4c-18f4-4647-be8c-d3b40e1659bb)

Generated Narrative: MedicationRequest

Resource MedicationRequest "6d607d4c-18f4-4647-be8c-d3b40e1659bb"

Profile: Prescrição de Medicamento

status: COMPLETED

intent: ORDER

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

authoredOn: 2022-03-04

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

recorder: 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

DispenseRequests

-ValidityPeriodQuantity
*2022-02-24 --> 2022-03-0310

21. urn:uuid:8bea4fe3-0769-4318-b5a8-7d3a8c6f04bd (Medication/8bea4fe3-0769-4318-b5a8-7d3a8c6f04bd)

Generated Narrative: Medication

Resource Medication "8bea4fe3-0769-4318-b5a8-7d3a8c6f04bd"

Profile: Medicamento

code: Terminologia segundo CATMAT (Terminologia de Produto Medicinal Virtual (VMP) no Catálogo de Materiais (CATMAT)#BR0352317)

22. urn:uuid:d2176159-0427-42da-a727-636bbb042d97 (CarePlan/d2176159-0427-42da-a727-636bbb042d97)

Generated Narrative: CarePlan

Resource CarePlan "d2176159-0427-42da-a727-636bbb042d97"

Profile: Plano de Cuidados

status: ACTIVE

intent: PLAN

description: Repouso pós-medicação intramuscular

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

23. urn:uuid:22f0baea-50d7-429b-8767-3b07c9a8120e (CarePlan/22f0baea-50d7-429b-8767-3b07c9a8120e)

Generated Narrative: CarePlan

Resource CarePlan "22f0baea-50d7-429b-8767-3b07c9a8120e"

Profile: Atestado Digital

status: ACTIVE

intent: PLAN

category: Atestado Médico/Odontológico (Tipo de Documento#ATM)

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

addresses: urn:uuid:6f057e45-34ab-43d6-8fd5-53c1d3aa73b2

activity

24. urn:uuid:6f057e45-34ab-43d6-8fd5-53c1d3aa73b2 (Condition/6f057e45-34ab-43d6-8fd5-53c1d3aa73b2)

Generated Narrative: Condition

Resource Condition "6f057e45-34ab-43d6-8fd5-53c1d3aa73b2" Updated "2022-05-09 17:37:55+0000"

Profile: CID10 Avaliado

clinicalStatus: Active (Condition Clinical Status Codes#active)

category: Principal (Categoria do Diagnóstico#01)

code: Varizes esofagianas sem sangramento (Classificação Internacional de Doenças - Décima Revisão - CID-10#I859)

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

onset: 2023-06-16

note: Varizes esofagianas sem sangramento.