!!Guia de Implementação do Registro de Atendimento Clínico (RAC) da RNDS - Compilação de desenvolvimento local (v1.0.0) construída pelas ferramentas de compilação FHIR (HL7® FHIR® Standard). Veja o Diretório de versões publicadas

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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.

Usos:

• Este Perfil não é utilizado por nenhum perfil neste guia de implementação

You can also check for usages in the FHIR IG Statistics

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

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
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 Vínculo: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Vínculo: 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 Valor fixo: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Vínculo: 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
Fatias para extension				Conteúdo/regras para todas as fatias
extension:unidentifiedPatient	S	0..1	(Complexo)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0
Fatias para extension		3..3	Extension	Extension Fatia: Não ordenado, Aberto por 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 Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Vínculo: DocumentRelationshipType (required): The type of relationship between documents. Valor fixo: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Fatias para section	SC	1..*	BackboneElement	Seções do documento Fatia: Não ordenado, Aberto por profile:entry.resolve() Constraints: cmp-1, cmp-2
section:Todas as fatias				Conteúdo/regras para todas as fatias
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial Constraints: cmp-1, cmp-2
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) Constraints: cmp-1, cmp-2
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) Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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
Documentação para este formato

Terminologia Ligações

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

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
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

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Composition		0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
type
coding
code		1..1	code	Symbol in syntax defined by the system Valor fixo: RAC
Fatias para section				Conteúdo/regras para todas as fatias
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
Documentação para este formato

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
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 Vínculo: CommonLanguages (preferred): A human language. Vínculos adicionais Objetivo AllLanguages Vínculo máximo
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 Vínculo: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Vínculo: 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Valor fixo: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Vínculo: Modalidade Assistencial (required): Modalidade Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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
Fatias para extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
extension:unidentifiedPatient	S	0..1	(Complexo)	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
Fatias para extension		3..3	Extension	Extension Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Vínculo: DocumentRelationshipType (required): The type of relationship between documents. Valor fixo: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Fatias para section	SC	1..*	BackboneElement	Seções do documento Fatia: Não ordenado, Aberto por profile:entry.resolve() Constraints: cmp-1, cmp-2
section:Todas as fatias				Conteúdo/regras para todas as fatias
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) Vínculo: 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Vínculo: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Vínculo: 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 Vínculo: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	Ver section (Composition)	Nested Section
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por 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) Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:observacoes	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:prescricao	SC	0..1	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo General: 123456
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From a norma FHIR Vínculos adicionais Objetivo AllLanguages Vínculo máximo
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 From este IG
Composition.type	required	BRTipoDocumento(a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 From este IG
Composition.category	required	BRModalidadeAssistencial(a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 From este IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From a norma FHIR
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From a norma FHIR
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 a norma FHIR
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From a norma FHIR
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From a norma FHIR
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
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

Resumo

Obrigatório: 1 elemento(10 aninhado obrigatoriamente elementos)
Fixo: 1 elemento
Proibido: 63 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

• 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)

Maturidade: 1

Key Elements View

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
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 Vínculo: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Vínculo: 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 Valor fixo: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Vínculo: 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
Fatias para extension				Conteúdo/regras para todas as fatias
extension:unidentifiedPatient	S	0..1	(Complexo)	Dados do Indivíduo Não Identificado URL: http://www.saude.gov.br/fhir/r4/StructureDefinition/BRIndividuoNaoIdentificado-1.0
Fatias para extension		3..3	Extension	Extension Fatia: Não ordenado, Aberto por 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 Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Vínculo: DocumentRelationshipType (required): The type of relationship between documents. Valor fixo: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Fatias para section	SC	1..*	BackboneElement	Seções do documento Fatia: Não ordenado, Aberto por profile:entry.resolve() Constraints: cmp-1, cmp-2
section:Todas as fatias				Conteúdo/regras para todas as fatias
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial Constraints: cmp-1, cmp-2
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) Constraints: cmp-1, cmp-2
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) Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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 Constraints: cmp-1, cmp-2
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
Documentação para este formato

Terminologia Ligações

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

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
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

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Composition		0..*	BRConjuntoMinimoDados	Registro Atendimento Clínico
type
coding
code		1..1	code	Symbol in syntax defined by the system Valor fixo: RAC
Fatias para section				Conteúdo/regras para todas as fatias
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
Documentação para este formato

Snapshot View

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
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 Vínculo: CommonLanguages (preferred): A human language. Vínculos adicionais Objetivo AllLanguages Vínculo máximo
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 Vínculo: Estado do Documento (required): Estado do Documento
type	SΣ	1..1	CodeableConcept	Tipo de Documento Vínculo: 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Valor fixo: RAC
category	SΣ	1..1	CodeableConcept	Modalidade Assistencial Vínculo: Modalidade Assistencial (required): Modalidade Assistencial
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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
Fatias para extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
extension:unidentifiedPatient	S	0..1	(Complexo)	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
Fatias para extension		3..3	Extension	Extension Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo 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 Vínculo: DocumentRelationshipType (required): The type of relationship between documents. Valor fixo: replaces
target[x]		1..1	Reference()	Documento a Ser Substituído
extension		0..*	Extension	Additional content defined by implementations Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Fatias para section	SC	1..*	BackboneElement	Seções do documento Fatia: Não ordenado, Aberto por profile:entry.resolve() Constraints: cmp-1, cmp-2
section:Todas as fatias				Conteúdo/regras para todas as fatias
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) Vínculo: 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Vínculo: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Vínculo: 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 Vínculo: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	Ver section (Composition)	Nested Section
section:informacoesContatoAssistencial	SC	1..1	BackboneElement	Informações do Contato Assistencial Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por 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) Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:procedimentosRealizados	SC	0..*	BackboneElement	Procedimento(s) Realizado(s) Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:observacoes	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:alergiaReacaoAdversa	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:prescricao	SC	0..1	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por 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 Fatia: Não ordenado, Aberto por value:url
system	Σ	1..1	uri	The namespace for the identifier value Exemplo General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Exemplo General: 123456
section:planoCuidados	SC	0..1	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
section:atestadoMedicoOdontologico	SC	0..*	BackboneElement	Seções do documento Constraints: cmp-1, cmp-2
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 Fatia: Não ordenado, Aberto por value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From a norma FHIR Vínculos adicionais Objetivo AllLanguages Vínculo máximo
Composition.status	required	BREstadoDocumento http://www.saude.gov.br/fhir/r4/ValueSet/BREstadoDocumento-1.0 From este IG
Composition.type	required	BRTipoDocumento(a valid code from Tipo de Documento) http://www.saude.gov.br/fhir/r4/ValueSet/BRTipoDocumento-1.0 From este IG
Composition.category	required	BRModalidadeAssistencial(a valid code from Modalidade Assistencial) http://www.saude.gov.br/fhir/r4/ValueSet/BRModalidadeAssistencial-1.0 From este IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From a norma FHIR
Composition.relatesTo.code	required	Fixed Value: replaces http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From a norma FHIR
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 a norma FHIR
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From a norma FHIR
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From a norma FHIR
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
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

Resumo

Obrigatório: 1 elemento(10 aninhado obrigatoriamente elementos)
Fixo: 1 elemento
Proibido: 63 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

• 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)

Maturidade: 1