Introdução

Este perfil indica que uma observação específica representa um comentário de anotação de texto livre.

Escopo/Uso

Este perfil representa .​

Uso indevido

Este recurso não deve ser utilizado para representar recursos que LOINC 48767-8 Annotation comment [Interpretation] Narrative o valor fixado está errado pois, trata-se de uma Interpretação relacionada a resultado de exame laboratorial.

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

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Vínculo: LOINCCodes (example): Codes identifying names of simple observations. Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
version		0..0	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
display		0..0	string	Representation defined by the system
userSelected		0..0	boolean	If this coding was chosen directly by the user
text		0..0	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Paciente)	Who and/or what the observation is about
encounter	Σ	0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]	Σ	0..1	dateTime	Clinically relevant time/time-period for observation
value[x]	ΣC	1..1	string	Actual result
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 From a norma FHIR
Observation.code	example	Fixed Value: Código LOINC 48767-8 http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.component.code	example	LOINCCodes(a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

This structure is derived from Observation

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation			Observation
identifier		0..0
basedOn		0..0
partOf		0..0
category		0..0
code		1..1	CodeableConcept	Type of observation (code / type) Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
subject		1..1	Reference(Paciente)	Who and/or what the observation is about
focus		0..0
encounter		0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]		0..1	dateTime	Clinically relevant time/time-period for observation
issued		0..0
performer		0..0
value[x]		1..1	string	Actual result
interpretation		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
referenceRange		0..0
hasMember		0..0
derivedFrom		0..0
component		0..0
Documentação para este formato

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7
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	?!Σ	1..1	code	registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Vínculo: LOINCCodes (example): Codes identifying names of simple observations. Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
version		0..0	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
display		0..0	string	Representation defined by the system
userSelected		0..0	boolean	If this coding was chosen directly by the user
text		0..0	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Paciente)	Who and/or what the observation is about
encounter	Σ	0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]	Σ	0..1	dateTime	Clinically relevant time/time-period for observation
value[x]	ΣC	1..1	string	Actual result
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Vínculo: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
note		0..*	Annotation	Comments about the observation
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From a norma FHIR Vínculos adicionais Objetivo AllLanguages Vínculo máximo
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 From a norma FHIR
Observation.code	example	Fixed Value: Código LOINC 48767-8 http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason From a norma FHIR
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning From a norma FHIR
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto From a norma FHIR
Observation.component.code	example	LOINCCodes(a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason From a norma FHIR
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Key Elements View

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Vínculo: LOINCCodes (example): Codes identifying names of simple observations. Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
version		0..0	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
display		0..0	string	Representation defined by the system
userSelected		0..0	boolean	If this coding was chosen directly by the user
text		0..0	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Paciente)	Who and/or what the observation is about
encounter	Σ	0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]	Σ	0..1	dateTime	Clinically relevant time/time-period for observation
value[x]	ΣC	1..1	string	Actual result
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 From a norma FHIR
Observation.code	example	Fixed Value: Código LOINC 48767-8 http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.component.code	example	LOINCCodes(a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Differential View

This structure is derived from Observation

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation			Observation
identifier		0..0
basedOn		0..0
partOf		0..0
category		0..0
code		1..1	CodeableConcept	Type of observation (code / type) Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
subject		1..1	Reference(Paciente)	Who and/or what the observation is about
focus		0..0
encounter		0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]		0..1	dateTime	Clinically relevant time/time-period for observation
issued		0..0
performer		0..0
value[x]		1..1	string	Actual result
interpretation		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
referenceRange		0..0
hasMember		0..0
derivedFrom		0..0
component		0..0
Documentação para este formato

Snapshot View

Nome	Bandeiras	Card.	Tipo	Descrição e condicionalismos    Filter: Condicionantes Obrigações Vínculos
Observation	C	0..*	Observation	Measurements and simple assertions Constraints: obs-6, obs-7
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	?!Σ	1..1	code	registered | preliminary | final | amended + Vínculo: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Vínculo: LOINCCodes (example): Codes identifying names of simple observations. Valor fixo: Como mostrado (Annotation comment [Interpretation] Narrative)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
coding		1..1	Coding	Code defined by a terminology system Valor fixo: (complexo)
id		0..0	string	Unique id for inter-element referencing
extension		0..0	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Valor fixo: http://loinc.org
version		0..0	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Valor fixo: 48767-8
display		0..0	string	Representation defined by the system
userSelected		0..0	boolean	If this coding was chosen directly by the user
text		0..0	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Paciente)	Who and/or what the observation is about
encounter	Σ	0..1	Reference(Contato Assistencial)	Healthcare event during which this observation is made
effective[x]	Σ	0..1	dateTime	Clinically relevant time/time-period for observation
value[x]	ΣC	1..1	string	Actual result
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Vínculo: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
note		0..*	Annotation	Comments about the observation
Documentação para este formato

Terminologia Ligações

Caminho	Conformidade	ValueSet / Código	URI
Observation.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From a norma FHIR Vínculos adicionais Objetivo AllLanguages Vínculo máximo
Observation.status	required	ObservationStatus http://hl7.org/fhir/ValueSet/observation-status|4.0.1 From a norma FHIR
Observation.code	example	Fixed Value: Código LOINC 48767-8 http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason From a norma FHIR
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes http://hl7.org/fhir/ValueSet/referencerange-meaning From a norma FHIR
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes http://hl7.org/fhir/ValueSet/referencerange-appliesto From a norma FHIR
Observation.component.code	example	LOINCCodes(a valid code from LOINC) http://hl7.org/fhir/ValueSet/observation-codes From a norma FHIR
Observation.component.dataAbsentReason	extensible	DataAbsentReason http://hl7.org/fhir/ValueSet/data-absent-reason From a norma FHIR
Observation.component.interpretation	extensible	ObservationInterpretationCodes http://hl7.org/fhir/ValueSet/observation-interpretation From a norma FHIR

Restrições

Id	Grau	Caminho(s)	Detalhes	Requisitos
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	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	Observation	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	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	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()
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

This structure is derived from Observation

Resumo

Obrigatório: 2 elementos
Fixo: 1 elemento
Proibido: 16 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

• Paciente (https://fhir.ipes.tech/fhir/StructureDefinition/PatientBRIPES)
• Contato Assistencial (https://fhir.ipes.tech/fhir/StructureDefinition/EncounterBRIPES)