Resumen Clínico del Paciente de Chile
0.4.0 - STU2
Resumen Clínico del Paciente de Chile
0.4.0 - STU2
Resumen Clínico del Paciente de Chile, published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.4.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/IPS-CL/ and changes regularly. See the Directory of published versions
| Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Observation-uso-de-alcohol-cl-ips | Version: 0.4.0 | |||
| Standards status: Draft | Maturity Level: 1 | Computable Name: ObservationUsoAlcoholClIps | ||
Este perfil restringe el recurso Observation para representar la evaluación del consumo de alcohol del paciente.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Observation |
C | 0..* | ObservacionCL | Measurements and simple assertions dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
 identifier |
SΣ | 0..* | Identifier | Identificación para la observación ele-1: All FHIR elements must have a @value or children |
| status |
?!SΣ | 1..1 | code | registered|preliminary|final|amended|corrected|cancelled|entered-in-error|unknown Binding: ObservationStatus (required): Códigos provistos para el estado de una observación ele-1: All FHIR elements must have a @value or children |
  Slices for category |
S | 1..* | CodeableConceptIPS | Concepto que referencia a una terminología o un texto acorde Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación ele-1: All FHIR elements must have a @value or children |
   category:historialSocial |
S | 1..1 | CodeableConcept | Clasificación del tipo de observación Binding: ObservationCategoryCodes (preferred): Códigos de alto nivel para la categoría de una observación ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: social-history | |
| code |
SΣ | 1..1 | CodeableConceptIPS | Tipo de observación (code/type) Binding: LOINCCodes (example): Códigos de identificación simple para el nombre de una observación ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74013-4 | |
 subject |
SΣ | 1..1 | Reference(Paciente) | Sobre Quien o Que se está realizando la observación ele-1: All FHIR elements must have a @value or children |
| reference |
SΣC | 1..1 | string | Referencia literal, interna o url absoluta ele-1: All FHIR elements must have a @value or children |
| encounter |
SΣ | 0..1 | Reference(CL Encuentro Clínico) | Evento clínico durante el cual se hizo esta observación ele-1: All FHIR elements must have a @value or children |
| effective[x] |
SΣ | 1..1 | dateTime | Tiempo/Tiempo-periodo de relevancia clínica para la observación ele-1: All FHIR elements must have a @value or children |
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
 data-absent-reason |
S | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| performer |
SΣ | 0..* | Reference(CL Prestador | CL RolClinico | CL Organización | CareTeam | CL Paciente | RelatedPerson) | Quien es responsable por la observación ele-1: All FHIR elements must have a @value or children |
| Slices for value[x] |
SΣC | 0..1 | Actual Resultado Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children | |
 valueQuantity |
Quantity | |||
| valueCodeableConcept |
CodeableConcept | |||
| valueString |
string | |||
| valueBoolean |
boolean | |||
| valueInteger |
integer | |||
| valueRange |
Range | |||
| valueRatio |
Ratio | |||
| valueSampledData |
SampledData | |||
| valueTime |
time | |||
| valueDateTime |
dateTime | |||
| valuePeriod |
Period | |||
| value[x]:valueQuantity |
SΣC | 0..1 | QuantityIPS | Una cantidad medida utilizando UCUM (Unified Code for Units of Measure). ele-1: All FHIR elements must have a @value or children |
| interpretation |
S | 0..* | CodeableConcept | Alta, baja, normal, etc Binding: ObservationInterpretationCodes (extensible): Códigos de identificación para la interpretación de la observación ele-1: All FHIR elements must have a @value or children |
| note |
S | 0..* | Annotation | Comentarios sobre la observación ele-1: All FHIR elements must have a @value or children |
| specimen |
S | 0..1 | Reference(Specimen) | Muestra tomada para la observación ele-1: All FHIR elements must have a @value or children |
| hasMember |
SΣ | 0..* | Reference(CL Observación | QuestionnaireResponse | MolecularSequence) | Grupo de recursos relacionados a la observación ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Observation.status | required | ObservationStatushttp://hl7.org/fhir/ValueSet/observation-status|4.0.1from the FHIR Standard | |
| Observation.category | preferred | ObservationCategoryCodeshttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.category:historialSocial | preferred | Pattern: social-historyhttp://hl7.org/fhir/ValueSet/observation-categoryfrom the FHIR Standard | |
| Observation.code | example | Pattern: LOINC Code 74013-4http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard | |
| Observation.component.code | example | LOINCCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/observation-codesfrom the FHIR Standard | |
| Observation.component.interpretation | extensible | ObservationInterpretationCodeshttp://hl7.org/fhir/ValueSet/observation-interpretationfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
Other representations of profile: CSV, Excel, Schematron
