Atención de Urgencia Interoperable
0.1.2-qa-preview - qa-preview
Atención de Urgencia Interoperable
0.1.2-qa-preview - qa-preview
Atención de Urgencia Interoperable, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.2-qa-preview built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/IG_Urgencia/ and changes regularly. See the Directory of published versions
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Encounter_d1391b7b-302a-49f8-a908-8116599e137e"> </a><p class="res-header-id"><b>Generated Narrative: Encuentro d1391b7b-302a-49f8-a908-8116599e137e</b></p><a name="d1391b7b-302a-49f8-a908-8116599e137e"> </a><a name="hcd1391b7b-302a-49f8-a908-8116599e137e"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-EncounterUrg.html">Encuentro Urgencia</a></p></div><p><b>Acompañante</b>: false</p><p><b>identifier</b>: 126402-0025</p><p><b>status</b>: In Progress</p><blockquote><p><b>statusHistory</b></p><p><b>status</b>: Arrived</p><p><b>period</b>: 2024-10-25 13:18:00-0400 --> (ongoing)</p></blockquote><blockquote><p><b>statusHistory</b></p><p><b>status</b>: Triaged</p><p><b>period</b>: 2024-10-25 13:30:00-0400 --> (ongoing)</p></blockquote><blockquote><p><b>statusHistory</b></p><p><b>status</b>: In Progress</p><p><b>period</b>: 2024-10-25 14:12:00-0400 --> (ongoing)</p></blockquote><p><b>class</b>: <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-EMER">ActCode EMER</a>: emergency</p><p><b>priority</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/categorizacion-ugo C3}">Atención Prioritaria</span></p><p><b>subject</b>: <a href="Patient-6ec6dc25-4b65-4165-a545-9b796f60b997.html">Maria Josefína Perez Gonzalez(official) Female, DoB: 1974-12-25 ( Rol Único Nacional: 90000000-6 (use: official, ))</a></p><blockquote><p><b>participant</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ParticipationType ADM}">admitter</span></p><p><b>period</b>: 2024-10-25 13:18:00-0400 --> (ongoing)</p><p><b>individual</b>: <a href="Practitioner-b9f6967f-51b5-49f4-8576-ce9f588523c2.html">Practitioner Mario Donoso </a></p></blockquote><blockquote><p><b>participant</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/participant-type emergency}">Emergency</span></p><p><b>individual</b>: <a href="RelatedPerson-bb7f34f7-8f4e-42c8-aa84-1f64bf584a05.html">RelatedPerson Jose Luis Perez </a></p></blockquote><blockquote><p><b>participant</b></p><p><b>type</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/TipoParticipanteUrgencia triage}">Categorizador</span></p><p><b>period</b>: 2024-10-25 13:30:00-0400 --> (ongoing)</p><p><b>individual</b>: <a href="Practitioner-d04739d3-ba47-4f0f-920f-bcd66b474963.html">Practitioner Juan Carlos Perez Gonzalez(official)</a></p></blockquote><blockquote><p><b>participant</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ParticipationType ATND}">attender</span></p><p><b>period</b>: 2024-10-25 14:12:00-0400 --> (ongoing)</p><p><b>individual</b>: <a href="Bundle-EjBundleAtencion.html#urn-uuid-190cd208-48b1-4920-a283-6bc37cbde13a">Practitioner Luis Gonzalez (official)</a></p></blockquote><blockquote><p><b>participant</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ParticipationType CON}">consultant</span></p><p><b>period</b>: 2024-10-25 14:29:00-0400 --> (ongoing)</p><p><b>individual</b>: <a href="Bundle-EjBundleAtencion.html#urn-uuid-fbb0e12c-95ec-43f7-bff1-73009b307cb5">Practitioner Maria Fernandez (official)</a></p></blockquote><p><b>period</b>: 2024-10-25 13:18:00-0400 --> (ongoing)</p><p><b>reasonCode</b>: <span title="Codes:">Dolor abdominal de 24 horas de evolución</span></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Condition</b></td><td><b>Use</b></td><td><b>Rank</b></td></tr><tr><td style="display: none">*</td><td><a href="Bundle-EjBundleAtencion.html#urn-uuid-e27704ff-fa1a-4750-9d23-36ce567f35b0">Condition Acute appendicitis</a></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/diagnosis-role AD}">Admission diagnosis</span></td><td>1</td></tr></table><blockquote><p><b>hospitalization</b></p><p><b>Medio de Llegada</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/MedioDeLlegada 5}">Vehículo particular</span></p><p><b>Consulta por Accidente</b>: false</p><p><b>admitSource</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/Procedencia 9}">Domicilio</span></p></blockquote><p><b>serviceProvider</b>: <a href="Organization-5491b8d5-e06c-4f89-beb7-75a1989cdc81.html">Organization Hospital Clínico Metropolitano La Florida Dra. Eloísa Díaz Insunza</a></p></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_190cd208-48b1-4920-a283-6bc37cbde13a"> </a><p class="res-header-id"><b>Generated Narrative: Practicante / Profesional 190cd208-48b1-4920-a283-6bc37cbde13a</b></p><a name="190cd208-48b1-4920-a283-6bc37cbde13a"> </a><a name="hc190cd208-48b1-4920-a283-6bc37cbde13a"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-PrestadorProfesional.html">Prestador Profesional de Urgencia</a></p></div><p><b>identifier</b>: RUN/55555555-5 (use: official, )</p><p><b>name</b>: Luis Gonzalez (Official)</p><p><b>birthDate</b>: 1992-05-26</p><h3>Qualifications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>cert</td><td><span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/TituloProfesional 30}">Médico General</span></td></tr></table></div>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_fbb0e12c-95ec-43f7-bff1-73009b307cb5"> </a><p class="res-header-id"><b>Generated Narrative: Practicante / Profesional fbb0e12c-95ec-43f7-bff1-73009b307cb5</b></p><a name="fbb0e12c-95ec-43f7-bff1-73009b307cb5"> </a><a name="hcfbb0e12c-95ec-43f7-bff1-73009b307cb5"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-PrestadorProfesional.html">Prestador Profesional de Urgencia</a></p></div><p><b>identifier</b>: RUN/33333333-3 (use: official, )</p><p><b>name</b>: Maria Fernandez (Official)</p><p><b>birthDate</b>: 1995-09-12</p><blockquote><p><b>qualification</b></p><p><b>Mención profesional añadida al título profesional</b>: Cirugía General</p><p><b>identifier</b>: cert</p><p><b>code</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/TituloProfesional 1}">Médico Cirujano</span></p></blockquote><blockquote><p><b>qualification</b></p><p><b>identifier</b>: esp</p><p><b>code</b>: <span title="Codes:{https://interoperabilidad.minsal.cl/fhir/ig/urgencia/CodeSystem/EspecialidadMedica 18}">Gastroenterología Adulto</span></p></blockquote></div>
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<Observation>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Observation_7ea8cb9a-fc10-44ad-8c52-de03c4517b30"> </a><p class="res-header-id"><b>Generated Narrative: Observación 7ea8cb9a-fc10-44ad-8c52-de03c4517b30</b></p><a name="7ea8cb9a-fc10-44ad-8c52-de03c4517b30"> </a><a name="hc7ea8cb9a-fc10-44ad-8c52-de03c4517b30"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ObservacionAnamnesis.html">Observación Anamnesis</a></p></div><p><b>status</b>: Registered</p><p><b>code</b>: <span title="Codes:{http://snomed.info/sct 84100007}">Anamnesis</span></p><p><b>subject</b>: <a href="Patient-6ec6dc25-4b65-4165-a545-9b796f60b997.html">Maria Josefína Perez Gonzalez(official) Female, DoB: 1974-12-25 ( Rol Único Nacional: 90000000-6 (use: official, ))</a></p><p><b>encounter</b>: <a href="Bundle-Ej1BundleAdmision.html#urn-uuid-d1391b7b-302a-49f8-a908-8116599e137e">Encounter: extension = false; identifier = 126402-0025; status = arrived; class = emergency (ActCode#EMER); priority = Sin Categorizar; period = 2024-10-25 13:18:00-0400 --> (ongoing)</a></p><p><b>effective</b>: 2024-10-25 14:18:00-0400</p><p><b>performer</b>: <a href="Bundle-EjBundleAtencion.html#urn-uuid-190cd208-48b1-4920-a283-6bc37cbde13a">Practitioner Luis Gonzalez (official)</a></p><p><b>value</b>: MOTIVO DE CONSULTA:
Dolor abdominal de 24 horas de evolución.
HISTORIA ACTUAL:
Inicio en región periumbilical hace 24 horas, posteriormente migra a fosa iliaca derecha.
Intensidad progresiva, EVA actual 8/10.
Asociado a:
- Anorexia desde inicio de síntomas
- Náuseas y dos episodios de vómitos
- Sensación febril no cuantificada
Dolor aumenta al caminar y con movimientos bruscos.
No reporta diarrea ni síntomas urinarios.
Automedicación con Paracetamol sin alivio.
ANTECEDENTES:
Mórbidos: No
Quirúrgicos: No
Alergias: No
Medicamentos habituales: No
Última ingesta: >12 horas (anorexia)</p></div>
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Dolor abdominal de 24 horas de evolución.
HISTORIA ACTUAL:
Inicio en región periumbilical hace 24 horas, posteriormente migra a fosa iliaca derecha.
Intensidad progresiva, EVA actual 8/10.
Asociado a:
- Anorexia desde inicio de síntomas
- Náuseas y dos episodios de vómitos
- Sensación febril no cuantificada
Dolor aumenta al caminar y con movimientos bruscos.
No reporta diarrea ni síntomas urinarios.
Automedicación con Paracetamol sin alivio.
ANTECEDENTES:
Mórbidos: No
Quirúrgicos: No
Alergias: No
Medicamentos habituales: No
Última ingesta: >12 horas (anorexia)"/>
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<div xmlns="http://www.w3.org/1999/xhtml"><a name="Condition_e27704ff-fa1a-4750-9d23-36ce567f35b0"> </a><p class="res-header-id"><b>Generated Narrative: Condición e27704ff-fa1a-4750-9d23-36ce567f35b0</b></p><a name="e27704ff-fa1a-4750-9d23-36ce567f35b0"> </a><a name="hce27704ff-fa1a-4750-9d23-36ce567f35b0"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ConditionDiagnosticoLE.html">Condition Diagnostico</a></p></div><p><b>clinicalStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-clinical active}">Active</span></p><p><b>verificationStatus</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-ver-status provisional}">Provisional</span></p><p><b>category</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/condition-category encounter-diagnosis}">Encounter Diagnosis</span></p><p><b>code</b>: <span title="Codes:{http://hl7.org/fhir/sid/icd-10 K35}">Acute appendicitis</span></p><p><b>subject</b>: <a href="Patient-6ec6dc25-4b65-4165-a545-9b796f60b997.html">Maria Josefína Perez Gonzalez(official) Female, DoB: 1974-12-25 ( Rol Único Nacional: 90000000-6 (use: official, ))</a></p><p><b>encounter</b>: <a href="Bundle-Ej1BundleAdmision.html#urn-uuid-d1391b7b-302a-49f8-a908-8116599e137e">Encounter: extension = false; identifier = 126402-0025; status = arrived; class = emergency (ActCode#EMER); priority = Sin Categorizar; period = 2024-10-25 13:18:00-0400 --> (ongoing)</a></p><p><b>recorder</b>: <a href="Bundle-EjBundleAtencion.html#urn-uuid-190cd208-48b1-4920-a283-6bc37cbde13a">Practitioner Luis Gonzalez (official)</a></p><p><b>note</b>: </p><blockquote><div><p>Paciente con dolor abdominal agudo, compatible con apendicitis aguda.</p>
</div></blockquote></div>
</text>
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value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
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<verificationStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
<code value="provisional"/>
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</verificationStatus>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-category"/>
<code value="encounter-diagnosis"/>
</coding>
</category>
<code>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10"/>
<code value="K35"/>
<display value="Acute appendicitis"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/6ec6dc25-4b65-4165-a545-9b796f60b997"/>
</subject>
<encounter>
<reference value="urn:uuid:d1391b7b-302a-49f8-a908-8116599e137e"/>
</encounter>
<recorder>
<reference value="urn:uuid:190cd208-48b1-4920-a283-6bc37cbde13a"/>
</recorder>
<note>
<text
value="Paciente con dolor abdominal agudo, compatible con apendicitis aguda."/>
</note>
</Condition>
</resource>
<request>
<method value="POST"/>
<url value="Condition"/>
</request>
</entry>
</Bundle>