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

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Resource Profile: Registro de Atendimento Clínico (RAC)

Documento destinado a modelar dados essenciais de uma consulta realizada a um indivíduo no âmbito da atenção básica, especializada ou domiciliar.

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Composition	S	0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	final | entered-in-error Binding: Estado do Documento (required): Estado do Documento ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Tipo de Documento Binding: Tipo de Documento (required): Tipo de Documento ele-1: All FHIR elements must have a @value or children
coding	SΣ	1..1	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Binding: Modalidade Assistencial (required): Modalidade Assistencial ele-1: All FHIR elements must have a @value or children
coding	SΣ	1..1	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0)	Sujeito da Composição ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
unidentifiedPatient	S	0..*	(Complex)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for extension		3..3	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:gender	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"gender"
value[x]		1..1	code	Value of extension ele-1: All FHIR elements must have a @value or children
extension:birthYear	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"birthYear"
value[x]		1..1	date	Value of extension ele-1: All FHIR elements must have a @value or children
extension:reason	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"reason"
value[x]		1..1	CodeableConcept	Value of extension ele-1: All FHIR elements must have a @value or children
url		1..1	uri	"http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0"
date	SΣ	1..1	dateTime	Data/hora de Geração do Documento ele-1: All FHIR elements must have a @value or children
author	SΣ	1..*	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPessoaJuridicaProfissionalLiberal-1.0)	Reponsável pelo Contato Assistencial ele-1: All FHIR elements must have a @value or children
identifier	Σ	1..1	Identifier	Logical reference, when literal reference is not known ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
title	SΣ	1..1	string	Título do documento ele-1: All FHIR elements must have a @value or children
relatesTo		0..1	BackboneElement	Relação a Outros Documentos ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code		1..1	code	Tipo de Relacionamento Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Fixed Value: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Slices for section	SC	1..*	BackboneElement	Seções do documento Slice: Unordered, Open by profile:entry.resolve() cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..1	Reference(Contato Assistencial)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:problemasDiagnosticosAvaliados	SC	1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..*	Reference(Problema / Diagnóstico)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..*	Reference(Procedimento Realizado)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:observacoes	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..*	Reference(Medida Observada)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:prescricao	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..1	Reference(Plano de Cuidados)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..*	Reference(Atestado Digital)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 from this IG
Composition.type	required	BRTipoDocumento (a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 from this IG
Composition.category	required	BRModalidadeAssistencial (a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	Composition	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	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	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()

This structure is derived from BRConjuntoMinimoDados

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
type
coding
code		1..1	code	Symbol in syntax defined by the system Fixed Value: RAC
Slices for section				Content/Rules for all slices
section:problemasDiagnosticosAvaliados		1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s)
section:observacoes		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..*	Reference(Medida Observada)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:alergiaReacaoAdversa		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:prescricao		0..1	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section
type		0..0
identifier
use		0..0
type		0..0
system		1..1	uri	The namespace for the identifier value
value		1..1	string	The value that is unique
period		0..0
assigner		0..0
display		0..0
emptyReason		0..0
section		0..0
section:planoCuidados		0..1	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..1	Reference(Plano de Cuidados)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:atestadoMedicoOdontologico		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..*	Reference(Atestado Digital)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Composition	S	0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
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 Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	final | entered-in-error Binding: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Binding: Tipo de Documento (required): Tipo de Documento
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Binding: Modalidade Assistencial (required): Modalidade Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
subject	SΣ	1..1	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0)	Sujeito da Composição
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
unidentifiedPatient	S	0..*	(Complex)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0
id		0..1	string	Unique id for inter-element referencing
Slices for extension		3..3	Extension	Extension Slice: Unordered, Open by value:url
extension:gender	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"gender"
value[x]		1..1	code	Value of extension
extension:birthYear	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"birthYear"
value[x]		1..1	date	Value of extension
extension:reason	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"reason"
value[x]		1..1	CodeableConcept	Value of extension
url		1..1	uri	"http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0"
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
date	SΣ	1..1	dateTime	Data/hora de Geração do Documento
author	SΣ	1..*	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPessoaJuridicaProfissionalLiberal-1.0)	Reponsável pelo Contato Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
identifier	Σ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
title	SΣ	1..1	string	Título do documento
relatesTo		0..1	BackboneElement	Relação a Outros Documentos
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
code		1..1	code	Tipo de Relacionamento Binding: DocumentRelationshipType (required): The type of relationship between documents. Fixed Value: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Slices for section	SC	1..*	BackboneElement	Seções do documento Slice: Unordered, Open by profile:entry.resolve() cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
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
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..1	Reference(Contato Assistencial)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:problemasDiagnosticosAvaliados	SC	1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..*	Reference(Problema / Diagnóstico)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..*	Reference(Procedimento Realizado)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:observacoes	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..*	Reference(Medida Observada)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:prescricao	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..1	Reference(Plano de Cuidados)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..*	Reference(Atestado Digital)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 from this IG
Composition.type	required	BRTipoDocumento (a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 from this IG
Composition.category	required	BRModalidadeAssistencial (a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	Composition	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	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	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()

This structure is derived from BRConjuntoMinimoDados

Summary

Mandatory: 1 element(10 nested mandatory elements)
Fixed: 1 element
Prohibited: 63 elements

Structures

This structure refers to these other structures:

• Medida Observada (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRMedidaObservada)
• Alergia ou Reação Adversa (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRAlergiaReacaoAdversa-1.0)
• Registro de Prescrição de Medicamento (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRRegistroPrescricaoMedicamento)
• Plano de Cuidados (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPlanoCuidados-1.0)
• Atestado Digital (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRAtestado)

Maturity: 1

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition	S	0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	final | entered-in-error Binding: Estado do Documento (required): Estado do Documento ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Tipo de Documento Binding: Tipo de Documento (required): Tipo de Documento ele-1: All FHIR elements must have a @value or children
coding	SΣ	1..1	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Binding: Modalidade Assistencial (required): Modalidade Assistencial ele-1: All FHIR elements must have a @value or children
coding	SΣ	1..1	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0)	Sujeito da Composição ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
unidentifiedPatient	S	0..*	(Complex)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for extension		3..3	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:gender	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"gender"
value[x]		1..1	code	Value of extension ele-1: All FHIR elements must have a @value or children
extension:birthYear	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"birthYear"
value[x]		1..1	date	Value of extension ele-1: All FHIR elements must have a @value or children
extension:reason	S	1..1	Extension	Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
url		1..1	uri	"reason"
value[x]		1..1	CodeableConcept	Value of extension ele-1: All FHIR elements must have a @value or children
url		1..1	uri	"http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0"
date	SΣ	1..1	dateTime	Data/hora de Geração do Documento ele-1: All FHIR elements must have a @value or children
author	SΣ	1..*	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPessoaJuridicaProfissionalLiberal-1.0)	Reponsável pelo Contato Assistencial ele-1: All FHIR elements must have a @value or children
identifier	Σ	1..1	Identifier	Logical reference, when literal reference is not known ele-1: All FHIR elements must have a @value or children
system	Σ	1..1	uri	The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
title	SΣ	1..1	string	Título do documento ele-1: All FHIR elements must have a @value or children
relatesTo		0..1	BackboneElement	Relação a Outros Documentos ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code		1..1	code	Tipo de Relacionamento Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Fixed Value: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Slices for section	SC	1..*	BackboneElement	Seções do documento Slice: Unordered, Open by profile:entry.resolve() cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..1	Reference(Contato Assistencial)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:problemasDiagnosticosAvaliados	SC	1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..*	Reference(Problema / Diagnóstico)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	SC	1..*	Reference(Procedimento Realizado)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:observacoes	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..*	Reference(Medida Observada)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:prescricao	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..1	Reference(Plano de Cuidados)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
entry	C	1..*	Reference(Atestado Digital)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 from this IG
Composition.type	required	BRTipoDocumento (a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 from this IG
Composition.category	required	BRModalidadeAssistencial (a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	Composition	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	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	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()

Differential View

This structure is derived from BRConjuntoMinimoDados

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
type
coding
code		1..1	code	Symbol in syntax defined by the system Fixed Value: RAC
Slices for section				Content/Rules for all slices
section:problemasDiagnosticosAvaliados		1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s)
section:observacoes		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..*	Reference(Medida Observada)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:alergiaReacaoAdversa		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:prescricao		0..1	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section
type		0..0
identifier
use		0..0
type		0..0
system		1..1	uri	The namespace for the identifier value
value		1..1	string	The value that is unique
period		0..0
assigner		0..0
display		0..0
emptyReason		0..0
section		0..0
section:planoCuidados		0..1	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..1	Reference(Plano de Cuidados)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
section:atestadoMedicoOdontologico		0..*	BackboneElement	Seções do documento
title		0..0
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry		1..*	Reference(Atestado Digital)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
type		0..0
identifier		0..0
display		0..0
emptyReason		0..0
section		0..0
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition	S	0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
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 Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	final | entered-in-error Binding: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Binding: Tipo de Documento (required): Tipo de Documento
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Binding: Modalidade Assistencial (required): Modalidade Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
subject	SΣ	1..1	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuo-1.0)	Sujeito da Composição
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
unidentifiedPatient	S	0..*	(Complex)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0
id		0..1	string	Unique id for inter-element referencing
Slices for extension		3..3	Extension	Extension Slice: Unordered, Open by value:url
extension:gender	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"gender"
value[x]		1..1	code	Value of extension
extension:birthYear	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"birthYear"
value[x]		1..1	date	Value of extension
extension:reason	S	1..1	Extension	Extension
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
url		1..1	uri	"reason"
value[x]		1..1	CodeableConcept	Value of extension
url		1..1	uri	"http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0"
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
date	SΣ	1..1	dateTime	Data/hora de Geração do Documento
author	SΣ	1..*	Reference(http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPessoaJuridicaProfissionalLiberal-1.0)	Reponsável pelo Contato Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
identifier	Σ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
title	SΣ	1..1	string	Título do documento
relatesTo		0..1	BackboneElement	Relação a Outros Documentos
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
code		1..1	code	Tipo de Relacionamento Binding: DocumentRelationshipType (required): The type of relationship between documents. Fixed Value: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Slices for section	SC	1..*	BackboneElement	Seções do documento Slice: Unordered, Open by profile:entry.resolve() cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
section:All Slices				Content/Rules for all slices
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
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..1	Reference(Contato Assistencial)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:problemasDiagnosticosAvaliados	SC	1..*	BackboneElement	Problema(s)/Diagnóstico(s) Avaliado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..*	Reference(Problema / Diagnóstico)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	SC	1..*	Reference(Procedimento Realizado)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:observacoes	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..*	Reference(Medida Observada)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	0..*	Reference(Alergia ou Reação Adversa)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:prescricao	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..1	Reference(Registro de Prescrição de Medicamento)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..1	Reference(Plano de Cuidados)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
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
entry	C	1..*	Reference(Atestado Digital)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 from this IG
Composition.type	required	BRTipoDocumento (a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 from this IG
Composition.category	required	BRModalidadeAssistencial (a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 from this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:informacoesContatoAssistencial, Composition.section:problemasDiagnosticosAvaliados, Composition.section:procedimentosRealizados, Composition.section:observacoes, Composition.section:alergiaReacaoAdversa, Composition.section:prescricao, Composition.section:planoCuidados, Composition.section:atestadoMedicoOdontologico	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	Composition	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	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	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()

This structure is derived from BRConjuntoMinimoDados

Summary

Mandatory: 1 element(10 nested mandatory elements)
Fixed: 1 element
Prohibited: 63 elements

Structures

This structure refers to these other structures:

• Medida Observada (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRMedidaObservada)
• Alergia ou Reação Adversa (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRAlergiaReacaoAdversa-1.0)
• Registro de Prescrição de Medicamento (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRRegistroPrescricaoMedicamento)
• Plano de Cuidados (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRPlanoCuidados-1.0)
• Atestado Digital (http://www.saude.gov.br/fhir/r4/StructureDefinition/BRAtestado)

Maturity: 1