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
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
| Official URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRRegistroAtendimentoClinico | Version: 0.1.0 | |||
| Standards status: Informative | Maturity Level: 1 | Computable Name: BRRegistroAtendimentoClinico | ||
Documento destinado a modelar dados essenciais de uma consulta realizada a um indivíduo no âmbito da atenção básica, especializada ou domiciliar.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 | |
  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 |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 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 |
| coding | SΣ | 1..1 | Coding | Code defined by a terminology system |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| 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 |
| coding | SΣ | 1..1 | Coding | Code defined by a terminology system |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| 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 |
| unidentifiedPatient | S | 0..* | (Complex) | Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0 |
 Slices for extension | 3..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:gender | S | 1..1 | Extension | Extension |
| url | 1..1 | uri | "gender" | |
| value[x] | 1..1 | code | Value of extension | |
| extension:birthYear | S | 1..1 | Extension | Extension |
| url | 1..1 | uri | "birthYear" | |
| value[x] | 1..1 | date | Value of extension | |
| extension:reason | S | 1..1 | Extension | Extension |
| 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" | |
| 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 |
| identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known |
| 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 | |
| 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 | |
| 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 | |||
  modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | BREstadoDocumentohttp://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0from this IG | |
| Composition.type | required | BRTipoDocumento (a valid code from Tipo de Documento)http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0from this IG | |
| Composition.category | required | BRModalidadeAssistencial (a valid code from Modalidade Assistencial)http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0from this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.relatesTo.code | required | Fixed Value: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard |
| 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() |
| 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.
| |||||
| 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..* | 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | BREstadoDocumentohttp://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0from this IG | ||||
| Composition.type | required | BRTipoDocumento (a valid code from Tipo de Documento)http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0from this IG | ||||
| Composition.category | required | BRModalidadeAssistencial (a valid code from Modalidade Assistencial)http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0from this IG | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | Fixed Value: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| 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 Value: 1 element
Prohibited: 63 elements
Structures
This structure refers to these other structures:
Maturity: 1
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 | |
| 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 | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | S | 0..* | BRConjuntoMinimoDados | Registro Atendimento Clínico |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| 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 |
| coding | SΣ | 1..1 | Coding | Code defined by a terminology system |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| 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 |
| coding | SΣ | 1..1 | Coding | Code defined by a terminology system |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| 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 |
| unidentifiedPatient | S | 0..* | (Complex) | Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0 |
| Slices for extension | 3..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:gender | S | 1..1 | Extension | Extension |
| url | 1..1 | uri | "gender" | |
| value[x] | 1..1 | code | Value of extension | |
| extension:birthYear | S | 1..1 | Extension | Extension |
| url | 1..1 | uri | "birthYear" | |
| value[x] | 1..1 | date | Value of extension | |
| extension:reason | S | 1..1 | Extension | Extension |
| 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" | |
| 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 |
| identifier | Σ | 1..1 | Identifier | Logical reference, when literal reference is not known |
| 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 | |
| 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 | |
| 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 | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | BREstadoDocumentohttp://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0from this IG | |
| Composition.type | required | BRTipoDocumento (a valid code from Tipo de Documento)http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0from this IG | |
| Composition.category | required | BRModalidadeAssistencial (a valid code from Modalidade Assistencial)http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0from this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.relatesTo.code | required | Fixed Value: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard |
| 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() |
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.
| |||||
| 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..* | 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | BREstadoDocumentohttp://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0from this IG | ||||
| Composition.type | required | BRTipoDocumento (a valid code from Tipo de Documento)http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0from this IG | ||||
| Composition.category | required | BRModalidadeAssistencial (a valid code from Modalidade Assistencial)http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0from this IG | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | Fixed Value: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| 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 Value: 1 element
Prohibited: 63 elements
Structures
This structure refers to these other structures:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron