Guia de Implementação do Registro de Atendimento Clínico (RAC) da RNDS
0.1.0 - CI Build
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
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
author: http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0
/3191384
title: Registro de Atendimento Clínico
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: ??
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: ??
Performers
Extension Function Actor OnBehalfOf 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: ??
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)
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: ??
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"
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
/3191384title: 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: ??
authoredOn: 2022-03-04
requester:
http://www.saude.gov.br/fhir/r4/StructureDefinition/BREstabelecimentoSaude-1.0
/3191384recorder:
http://www.saude.gov.br/fhir/r4/StructureDefinition/BRProfissional-1.0
/162338254590005note: Medicamento necessário para tratamento da febre devido à gripe. (By Dr. Getúlio @2022-03-04)
dosageInstruction
DispenseRequests
ValidityPeriod Quantity 2022-02-24 --> 2022-03-03 10
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)
Resource CarePlan "d2176159-0427-42da-a727-636bbb042d97"
Profile: Plano de Cuidados
status: ACTIVE
intent: PLAN
description: Repouso pós-medicação intramuscular
subject: ??
23. urn:uuid:22f0baea-50d7-429b-8767-3b07c9a8120e (CarePlan/22f0baea-50d7-429b-8767-3b07c9a8120e)
Resource CarePlan "22f0baea-50d7-429b-8767-3b07c9a8120e"
Profile: Atestado Digital
status: ACTIVE
intent: PLAN
category: Atestado Médico/Odontológico (Tipo de Documento#ATM)
subject: ??
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: ??
onset: 2023-06-16
note: Varizes esofagianas sem sangramento.