Composición de un Resumen Clínico de Paciente Para Chile. Una composición es un conjunto de información relacionada con la asistencia sanitaria que se ensambla en un único documento lógico que proporciona una única declaración coherente de significado, establece su propio contexto y que tiene atestación clínica con respecto a quién realiza la declaración. Aunque una composición define la estructura, en realidad no contiene el contenido: el contenido completo de un documento se encuentra en un paquete, cuyo primer recurso es la composición.

Especifica que el documento refiere al Resumen de Paciente (Loinc "60591-5")

Sobre quién o que es el documento. En general, una composición puede referirse a una persona (paciente o profesional sanitario), a un dispositivo (por ejemplo, una máquina) o incluso a un grupo de sujetos (como un documento sobre un rebaño de ganado o un conjunto de pacientes que comparten una exposición común). Para el IPS, el sujeto es siempre el paciente.

Identifica al responsable de la información en el IPS, no necesariamente a quien la ingresó.

El tipo de autor, de manera de determinar la "naturaleza"del resumen de paciente: e.g. a "Datos curativos" IPS Vs. uno generado "automaticamente".

Etiqueta oficial de lectura humana para el documento.

Para este documento debiera ser "Resumen de Paciente Basado en IPS"

La prestación de asistencia sanitaria durante un periodo de tiempo que este IPS está documentando.

Las seccion es raíz que componen el documento IPS.

La sección de resumen de medicación contiene una descripción de los medicamentos del paciente relevantes para el ámbito del resumen del paciente. Se puede reportar:

• Medicamentos activos;
• medicamentos usados actualmente o usados anteriormente considerados relevantes para el autor;
• Prescripciones o dispensaciones extraidos automáticamente de RCE.

En esos casos, los medicamentos se documentan en el Resumen del Paciente como declaraciones de medicación o solicitudes de medicación. Esta sección requiere o bien una entrada que indique que se sabe que el sujeto no toma ninguna medicación relevante; o bien una entrada que indique que no se dispone de información sobre medicaciones; o bien entradas que resuman las medicaciones relevantes del sujeto.

Título de la sección específica. Será parte de la renderización para uso dentro de la la tabla de contenidos.

Resumen de Medicamento

Esta lista los medicamentos relevantes para el ámbito del resumen del paciente o se utiliza para indicar que se sabe que el sujeto no toma ninguna medicación relevante; o bien que no se dispone de información sobre medicamentos.

Esta sección documenta las alergias o intolerancias (afecciones) relevantes para ese paciente, describiendo el tipo de reacción (por ejemplo, erupción cutánea, anafilaxia, etc.); preferiblemente los agentes que la causan; y opcionalmente la criticidad y la certeza de la alergia.

Enumera las alergias o intolerancias (afecciones) relevantes para ese paciente, describiendo el tipo de reacción (por ejemplo, erupción cutánea, anafilaxia,..); preferiblemente los agentes que la causan; y opcionalmente la criticidad y la certeza de la alergia. Como mínimo, debe enumerar las alergias y reacciones adversas actualmente activas y cualquier historial relevante. Esta entrada se utilizará para documentar que no se dispone de información sobre alergias, o que no se conocen alergias

La sección de problemas del IPS enumera y describe los problemas o condiciones clínicas que se están controlando actualmente para el paciente.

Enumera y describe los problemas o afecciones clínicas que se están controlando actualmente en el paciente. Esta entrada se utilizará para documentar que no se dispone de información sobre problemas o que no se conocen problemas relevantes.

La sección Historial de procedimientos contiene una descripción de los procedimientos anteriores del paciente que son pertinentes para el ámbito de este documento. Como por ejemplo:

1. Procedimientos invasivos:e.g. Caterización Cardiaca; (los resultados de este procedimiento se documentan en la sección de resultados)
2. Procedimientos Terapéuticos: e.j. diálisis;
3. Procedimientos Quirúrjicos: e.j. Apendicectomía

Enumera los procedimientos anteriores del paciente que son pertinentes para el ámbito de este documento. Procedimiento diagnóstico invasivo: por ejemplo, cateterismo cardíaco (los resultados de este procedimiento se documentan en la sección de resultados). Procedimiento terapéutico: p. ej. diálisis; 3. Procedimiento quirúrgico: por ejemplo, apendicectomía. Esta entrada se utilizará para documentar que no se dispone de información sobre procedimientos anteriores, o que no se conocen procedimientos anteriores relevantes.

La sección de dispositivos médicos contiene texto narrativo y entradas codificadas que describen el historial de uso de dispositivos médicos por parte del paciente.

Describe el historial de uso de productos sanitarios del paciente. Esta entrada se utilizará para documentar que no se dispone de información sobre el uso de productos sanitarios o que no se conoce ningún uso relevante de productos sanitarios.

Esta sección reúne los resultados de observación pertinentes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Algunos de estos resultados pueden ser de laboratorio, otros de anatomía patológica, otros de radiología y otros clínicos.

Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Algunos de estos resultados pueden ser de laboratorio, otros de anatomía patológica, otros de radiología y otros clínicos.

La sección de signos vitales incluye la tensión arterial, la temperatura corporal, la frecuencia cardiaca y la frecuencia respiratoria. También puede incluir otros hallazgos clínicos, como la altura, el peso, el índice de masa corporal, el perímetro cefálico y la pulsioximetría. En particular, pueden incluirse las constantes vitales o los hallazgos físicos notables, como los más recientes, los máximos y/o mínimos, la línea de base o las tendencias relevantes

Signos vitales o hallazgos físicos de relevancia como: tensión arterial, temperatura corporal, frecuencia cardiaca y frecuencia respiratoria. También puede incluir otros hallazgos clínicos, como altura, peso, índice de masa corporal, perímetro cefálico y pulsioximetría. En particular, pueden incluirse constantes vitales o hallazgos físicos relevantes como los más recientes, máximos y/o mínimos, línea de base, o tendencias relevantes

La sección Historial de enfermedades anteriores contiene una descripción de las afecciones que el paciente padeció en el pasado.

Contiene una descripción de las afecciones que sufrió el paciente en el pasado.

La sección de estado funcional contendrá una descripción narrativa de la capacidad del paciente para realizar actos de la vida diaria, incluidas las posibles necesidades del paciente de ser evaluado continuamente por terceros. De hecho, el estado de invalidez puede influir en las decisiones sobre cómo administrar los tratamientos. Los perfiles para expresar las discapacidades y las evaluaciones funcionales se especificarán en futuras versiones de esta guía.

Describe las capacidades del paciente para realizar actos de la vida diaria, incluidas las posibles necesidades del paciente de ser evaluado continuamente por terceros. De hecho, el estado de invalidez puede influir en las decisiones sobre cómo administrar los tratamientos. Los perfiles para expresar las discapacidades y las evaluaciones funcionales se especificarán en futuras versiones de esta guía.

La sección del plan de cuidados contiene una descripción narrativa de las expectativas de los cuidados, incluidas las propuestas, los objetivos y las solicitudes de órdenes para la supervisión, el seguimiento o la mejora del estado del paciente.

Plan dinámico y personalizado que incluye la actividad sanitaria necesaria identificada, los objetivos sanitarios y las metas sanitarias, en relación con uno o más problemas de salud especificados en un proceso sanitario [Fuente EN ISO 13940].

La sección de historia social contiene una descripción de los "factores de estilo de vida" u "observaciones de estilo de vida" reñacionados con la salud del paciente (e.j. Hábitos de fumar; consumo de alcohol; dietas; hábitos de riesgo).

Descripción de los «factores de estilo de vida» relacionados con la salud de la persona" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.)

La sección de antecedentes de embarazo contendrá información sobre si la paciente está o no embarazada en la actualidad.

Contiene información sobre si la paciente está embarazada o no. Puede contener además información resumida sobre el resultado de embarazos anteriores.

La sección de alertas señala posibles preocupaciones y/o peligros para/del paciente y también puede incluir obstáculos para la atención.

Contiene información de alertas que se deben comunicar. Opcionalmente, puede hacer referencia a otros recursos en IPS-CL.

La sección de consentimientos contiene una descripción narrativa de las voluntades anticipadas del paciente.

Contiene una descripción narrativa o una entrada de Consentimiento con información sobre la directiva anticipada del paciente.

Composición de un Resumen Clínico de Paciente Para Chile. Una composición es un conjunto de información relacionada con la asistencia sanitaria que se ensambla en un único documento lógico que proporciona una única declaración coherente de significado, establece su propio contexto y que tiene atestación clínica con respecto a quién realiza la declaración. Aunque una composición define la estructura, en realidad no contiene el contenido: el contenido completo de un documento se encuentra en un paquete, cuyo primer recurso es la composición.

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identificador para el recurso que contiene documento, puede ser usado de manera local. Este idetificador es independiente de la versión del documento

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Estado del documento

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

Códigos requeridos por estándar

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Especifica que el documento refiere al Resumen de Paciente (Loinc "60591-5")

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Key metadata element describing the composition, used in searching/filtering.

Sobre quién o que es el documento. En general, una composición puede referirse a una persona (paciente o profesional sanitario), a un dispositivo (por ejemplo, una máquina) o incluso a un grupo de sujetos (como un documento sobre un rebaño de ganado o un conjunto de pacientes que comparten una exposición común). Para el IPS, el sujeto es siempre el paciente.

For clinical documents, this is usually the patient.

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Contexto en el cual se generó el documento.

Provides context for the composition and supports searching.

Fecha de edición del documento, cuando este fue modificado por el autor

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Identifica al responsable de la información en el IPS, no necesariamente a quien la ingresó.

El tipo de autor, de manera de determinar la "naturaleza"del resumen de paciente: e.g. a "Datos curativos" IPS Vs. uno generado "automaticamente".

Identifies who is responsible for the content.

Etiqueta oficial de lectura humana para el documento.

Para este documento debiera ser "Resumen de Paciente Basado en IPS"

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Profesionales validadores del documento

Only list each attester once.

Identifies responsibility for the accuracy of the composition content.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of attestation the authenticator offers.

Códigos requeridos por FHIR

Indicates the level of authority of the attestation.

Fecha y Hora de la validación

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Quien validó

Identifies who has taken on the responsibility for accuracy of the composition content.

Referencia a la organización según perfil nacional

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Identifies where to go to find the current version, where to report issues, etc.

The clinical service, such as a colonoscopy or an appendectomy, being documented.

The event needs to be consistent with the type element, though can provide further information if desired.

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

La prestación de asistencia sanitaria durante un periodo de tiempo que este IPS está documentando.

The event needs to be consistent with the type element, though can provide further information if desired.

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

This list of codes represents the main clinical acts being documented.

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

Las seccion es raíz que componen el documento IPS.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

If a section is empty, why it is empty.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

A nested sub-section within this section.

Nested sections are primarily used to help human readers navigate to particular portions of the document.

La sección de resumen de medicación contiene una descripción de los medicamentos del paciente relevantes para el ámbito del resumen del paciente. Se puede reportar:

• Medicamentos activos;
• medicamentos usados actualmente o usados anteriormente considerados relevantes para el autor;
• Prescripciones o dispensaciones extraidos automáticamente de RCE.

En esos casos, los medicamentos se documentan en el Resumen del Paciente como declaraciones de medicación o solicitudes de medicación. Esta sección requiere o bien una entrada que indique que se sabe que el sujeto no toma ninguna medicación relevante; o bien una entrada que indique que no se dispone de información sobre medicaciones; o bien entradas que resuman las medicaciones relevantes del sujeto.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Título de la sección específica. Será parte de la renderización para uso dentro de la la tabla de contenidos.

Resumen de Medicamento

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Esta lista los medicamentos relevantes para el ámbito del resumen del paciente o se utiliza para indicar que se sabe que el sujeto no toma ninguna medicación relevante; o bien que no se dispone de información sobre medicamentos.

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Esta sección documenta las alergias o intolerancias (afecciones) relevantes para ese paciente, describiendo el tipo de reacción (por ejemplo, erupción cutánea, anafilaxia, etc.); preferiblemente los agentes que la causan; y opcionalmente la criticidad y la certeza de la alergia.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Enumera las alergias o intolerancias (afecciones) relevantes para ese paciente, describiendo el tipo de reacción (por ejemplo, erupción cutánea, anafilaxia,..); preferiblemente los agentes que la causan; y opcionalmente la criticidad y la certeza de la alergia. Como mínimo, debe enumerar las alergias y reacciones adversas actualmente activas y cualquier historial relevante. Esta entrada se utilizará para documentar que no se dispone de información sobre alergias, o que no se conocen alergias

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

La sección de problemas del IPS enumera y describe los problemas o condiciones clínicas que se están controlando actualmente para el paciente.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Enumera y describe los problemas o afecciones clínicas que se están controlando actualmente en el paciente. Esta entrada se utilizará para documentar que no se dispone de información sobre problemas o que no se conocen problemas relevantes.

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

La sección Historial de procedimientos contiene una descripción de los procedimientos anteriores del paciente que son pertinentes para el ámbito de este documento. Como por ejemplo:

1. Procedimientos invasivos:e.g. Caterización Cardiaca; (los resultados de este procedimiento se documentan en la sección de resultados)
2. Procedimientos Terapéuticos: e.j. diálisis;
3. Procedimientos Quirúrjicos: e.j. Apendicectomía

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Enumera los procedimientos anteriores del paciente que son pertinentes para el ámbito de este documento. Procedimiento diagnóstico invasivo: por ejemplo, cateterismo cardíaco (los resultados de este procedimiento se documentan en la sección de resultados). Procedimiento terapéutico: p. ej. diálisis; 3. Procedimiento quirúrgico: por ejemplo, apendicectomía. Esta entrada se utilizará para documentar que no se dispone de información sobre procedimientos anteriores, o que no se conocen procedimientos anteriores relevantes.

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Sección de notificación definida para el documento.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

La sección de dispositivos médicos contiene texto narrativo y entradas codificadas que describen el historial de uso de dispositivos médicos por parte del paciente.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Describe el historial de uso de productos sanitarios del paciente. Esta entrada se utilizará para documentar que no se dispone de información sobre el uso de productos sanitarios o que no se conoce ningún uso relevante de productos sanitarios.

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Esta sección reúne los resultados de observación pertinentes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Algunos de estos resultados pueden ser de laboratorio, otros de anatomía patológica, otros de radiología y otros clínicos.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Código que define el tipo de sección

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Provides computable standardized labels to topics within the document.

Texto que describe el contenido de la sección

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Algunos de estos resultados pueden ser de laboratorio, otros de anatomía patológica, otros de radiología y otros clínicos.

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

Puede ser cualquier recurso en función de la sección que se está notificando

If there are no entries in the list, an emptyReason SHOULD be provided.

La sección de signos vitales incluye la tensión arterial, la temperatura corporal, la frecuencia cardiaca y la frecuencia respiratoria. También puede incluir otros hallazgos clínicos, como la altura, el peso, el índice de masa corporal, el perímetro cefálico y la pulsioximetría. En particular, pueden incluirse las constantes vitales o los hallazgos físicos notables, como los más recientes, los máximos y/o mínimos, la línea de base o las tendencias relevantes