Resumen Clínico de Pacientes Embarazadas Chile
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Resumen Clínico de Pacientes Embarazadas Chile, published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile-BiomedicaUv/IPS-Embarazo/ and changes regularly. See the Directory of published versions

Example Bundle: Bundle - Ejemplo

Document Details

Generated Narrative: Bundle Resumen Clínico de Pacientes Embarazadas - Chile

Document Subject

Generated Narrative: Patient 6e251b4d-1ed9-48b9-850a-138d9849507c

Susana Mercedes Henriquez (official) Female, DoB: 1995-05-01 ( Chile: 14.241.432-8 (use: official, ))


Active:true
Contact Detail
  • ph: 932785678(Mobile)
  • Av. General Vidaurre, casa 84 G Valparaíso Valparaíso Chile (home)
Edad del paciente38

Document Content

Medicamentos

  • Medication Name: Calcio (medicamento)
    Code: 7947003
    Status: active, started 2024-08-03
    Instructions: Administrar 200 mg por día

Alergias

  • Allergy Name: Hierro
    Verification Status: Confirmado
    Reaction: Anafilaxia

Problemas de salud - Condiciones

  • Condition Name: Obesidad
    Code: 414916001
    Status: active

Observación: Embarazo

La paciente presentó un estado de embarazo positivo (Embarazada) el día 03 de marzo del presente año. Como resultado, se obtuvo que tiene un hijo.

Procedimientos

La paciente se realizó una cesárea categorizada como procedimiento obstétrico el día 26 de noviembre del presente año.

Additional Resources Included in Document


Entry 1 - fullUrl = urn:uuid:1637493f-e222-4005-ac6b-17e7d17122e0

Rec}:

Generated Narrative: Composition 1637493f-e222-4005-ac6b-17e7d17122e0

status: Final

type: Documento resumen de paciente embarazada

date: 2024-12-03

author: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

title: Resumen Clínico de Pacientes Embarazadas - Chile

custodian: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

relatesTo

No display for RelatedArtifact (type: appends)

Entry 2 - fullUrl = urn:uuid:6e251b4d-1ed9-48b9-850a-138d9849507c

Rec}:

Generated Narrative: Patient 6e251b4d-1ed9-48b9-850a-138d9849507c

Susana Mercedes Henriquez (official) Female, DoB: 1995-05-01 ( Chile: 14.241.432-8 (use: official, ))


Active:true
Contact Detail
  • ph: 932785678(Mobile)
  • Av. General Vidaurre, casa 84 G Valparaíso Valparaíso Chile (home)
Edad del paciente38

Entry 3 - fullUrl = urn:uuid:503a0267-1cfd-44cc-a382-e052a78fa5cc

Rec}:

Generated Narrative: Practitioner 503a0267-1cfd-44cc-a382-e052a78fa5cc

identifier: RUN/15325467-k (use: official, )

name: Bernarda Antonella Zuñiga (Official)

telecom: Bernarda.antonellaCesfam@hotmail.com


Entry 4 - fullUrl = urn:uuid:e80c16ae-eec7-4ff7-99c4-27e756ace6fa

Rec}:

Generated Narrative: Organization e80c16ae-eec7-4ff7-99c4-27e756ace6fa

identifier: https://datos.gob.cl/dataset/establecimientos-de-salud-vigentes/resource/2c44d782-3365-44e3-aefb-2c8b8363a1bc/106302

name: Centro de Salud Familiar Barón

alias: CESFAM Barón

Contacts

-Telecom
*cesfam.baron@gmail.com

Entry 5 - fullUrl = urn:uuid:f6759f7e-630f-400e-bbe2-c8378fa6a1a5

Rec}:

Generated Narrative: MedicationStatement f6759f7e-630f-400e-bbe2-c8378fa6a1a5

status: recorded

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

effective: 2024-08-03 --> (ongoing)

note: ### NOTA: Administrar una tableta por día a partir de las 20 semanas hasta el final de la gestación.

dosage

text: Administrar 200 mg/día

timing: Once per 1 days

route: Vía de administración bucal

DoseAndRates

-Dose[x]
*200 mg (Details: UCUM codemg = 'mg')

Entry 6 - fullUrl = urn:uuid:edbe2197-1ead-44d3-b572-4b26de4fb427

Rec}:

Generated Narrative: Medication edbe2197-1ead-44d3-b572-4b26de4fb427

Language: es

Profile: Medicamentos (Embarazo-CL)

Nombre Comercial Fármaco: Calcio

code: Calcio (medicamento)

status: Active


Entry 7 - fullUrl = urn:uuid:b16e76cc-8ee5-4ede-9dc9-7329aa49292c

Rec}:

Generated Narrative: MedicationRequest b16e76cc-8ee5-4ede-9dc9-7329aa49292c

status: Completed

intent: Original Order

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

requester: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

dosageInstruction

text: Administrar 200 mg por día hasta el final de la gestación.

timing: Once per 1 days

route: Vía de administración bucal

DoseAndRates

-Dose[x]
*200 mg (Details: UCUM codemg = 'mg')

Entry 8 - fullUrl = urn:uuid:4383be84-d431-47e1-85e7-80d995742514

Rec}:

Generated Narrative: AllergyIntolerance 4383be84-d431-47e1-85e7-80d995742514

clinicalStatus: Activo

verificationStatus: Confirmado

type: Allergy

criticality: High Risk

code: Hierro

patient: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

onset: 15 años (Details: UCUM codea = 'a')

note: ### NOTA: El cuadro clínico que suele presentar la paciente ante la exposición a Hierro es **intenso picor en manos y cuero cabelludo.** Además, presenta **taquitardia y dificultad respiratoria.**

Reactions

-Manifestation
*No display for AllergyIntolerance.reaction.manifestation (concept: Anaphylaxis)

Entry 9 - fullUrl = urn:uuid:fd5676b3-0011-49a3-9c21-d1bd8458f350

Rec}:

Generated Narrative: Condition fd5676b3-0011-49a3-9c21-d1bd8458f350

clinicalStatus: Activa

category: Problema

severity: Moderado

code: Obesidad

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

onset: 2023-10-30 --> (ongoing)

note: ### NOTA: La paciente durante su post parto anterior presentó hipertensión arterial, dada su condición de salud.


Entry 10 - fullUrl = urn:uuid:44f4b385-d48d-4a7b-8959-3b87f3b23ebe

Rec}:

Generated Narrative: Procedure 44f4b385-d48d-4a7b-8959-3b87f3b23ebe

status: Completed

category: Procedimiento obstétrico

code: Cesárea

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

note: ### NOTA: La paciente se realizó el procedimiento obstétrico de cesárea con fecha 03 de diciembre del presente año. En este caso, la fecha representa la fecha de nacimiento del bebé.


Entry 11 - fullUrl = urn:uuid:ea4b4cb7-d449-4b7e-978c-2a446bd547b1

Rec}:

Generated Narrative: Observation ea4b4cb7-d449-4b7e-978c-2a446bd547b1

status: Final

code: Estado de embarazo

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

effective: 2024-03-03

performer: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

value: Embarazada

note: ### NOTA: El estado de embarazo positivo se dió el día 03 de marzo del 2024.

hasMember: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400


Entry 12 - fullUrl = urn:uuid:76555e43-8a81-4821-92aa-cab7c57010f0

Rec}:

Generated Narrative: Observation 76555e43-8a81-4821-92aa-cab7c57010f0

status: Final

code: [#] Nacimientos totales

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

effective: 2022-08-18

performer: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

value: 1 hijo (Details: UCUM code1 = '1')


Entry 13 - fullUrl = urn:uuid:660b0997-ec98-4981-92ee-bd7b5d44d215

Rec}:

Generated Narrative: Observation 660b0997-ec98-4981-92ee-bd7b5d44d215

status: Final

code: Fecha estimada de parto a partir del último periodo menstrual (FUR Operacional)

subject: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

effective: 2024-05-05

performer: Bundle: identifier = urn:oid:2.16.152.1.10.1#Document-Bundle-2024-001; type = document; timestamp = 2024-12-03 13:00:00-0400

value: 2024-11-26

note: ### NOTA: Se realizó una ecografía el día 05 de mayo (durante el primer trimestre) a la paciente para determinar la fecha de última regla de de manera más precisa (FUR Operacional). Por lo tanto, la fecha estimada de parto es en noviembre de este año.