HL7 PT FHIR Implementation Guide: Noticia de Nascimento
0.0.1 - STU1 Portugal flag

HL7 PT FHIR Implementation Guide: Noticia de Nascimento, published by HL7 Portugal. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-pt/obs-neonat-ig/ and changes regularly. See the Directory of published versions

Mapeamentos

O mapeamento não foi feito de forma direta, sendo que a estrutura foi alterada de forma a corresponder a um documento em FHIR. No entanto, tentou-se que a alteração fosse o menos profunda possível, de forma a facilitar a implementação Tentámos usar terminologias internacionais sempre que possíveis, criando CodeSystem quando não foi possível. Tentámos também vincular campos codificados a estas terminologias. De igual forma, criámos constraints adicionais para facilitar a transformação.

Aqui deixamos uma visão geral do modelo lógico e de como este se transforma na especificação FHIR:

Origem Descrição Modelo Lógico FHIR
    contact.id Encounter[Contact].identifier
    contact.module Encounter[Contact].class
    professional.functionalgroup Patient[Mother].generalPractitioner
    professional.licence Patient[Mother].generalPractitioner
    professional.name Patient[Mother].generalPractitioner
    birthNotice.owner -
    birthNotice.code -
    birthNotice.maternity.institution Encounter[Contact].serviceProvider
    birthNotice.maternity.service Encounter[Contact].serviceProvider
    birthNotice.destination.headquarters Organization
    birthNotice.destination.ACES Organization
    birthNotice.destination.healthcardNumber Organization
    birthNotice.destination.healthextension Organization
    birthNotice.destination.familyDoctor Patient[Mother].generalPractitioner
    birthNotice.destination.familyNurse Patient[Mother].generalPractitioner
    birthNotice.motherDemographics.healthcardNumber Patient.identifier
    birthNotice.motherDemographics.name Patient.name
    birthNotice.motherDemographics.birthdate Patient.birthDate
    birthNotice.motherDemographics.Age Patient.birthDate
    birthNotice.motherDemographics.address Patient.address
    birthNotice.motherDemographics.placeOfBirth Patient.extension.birthPlace
    birthNotice.motherDemographics.nationality Patient.extension.nationality
    birthNotice.motherDemographics.phone Patient.contact
    birthNotice.motherDemographics.postalCode Patient.address
    birthNotice.motherDemographics.countryOfBirth Patient.extension.birthPlace
    birthNotice.motherDemographics.districtOfBirth Patient.extension.birthPlace
    birthNotice.motherDemographics.countyOfBirth Patient.extension.birthPlace
    birthNotice.motherDemographics.parishOfBirth Patient.extension.birthPlace
    birthNotice.motherDemographics.districtAddress Patient.address
    birthNotice.motherDemographics.countyAddress Patient.address
    birthNotice.motherDemographics.parishAddress Patient.address
    birthNotice.pregnancy.days Observation[Pregancy].component
    birthNotice.pregnancy.weeks Observation[Pregancy].component
    birthNotice.pregnancy.risk Observation[Pregancy].component
    birthNotice.pregnancy.riskReason Observation[Pregancy].component
    birthNotice.pregnancy.immunoglobulinAdministration Vaccination.status
    birthNotice.pregnancy.immunoglobulinAdministrationDate Vaccination.effectiveDateTime
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.firstQuarterEco Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.firstQuarterBio Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.secondQuarterEco Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.secondQuarterBio Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.thirdQuarterEco Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.thirdQuarterBio Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.visits Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.intercurrences Observation[Pregancy].component
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.locals.type -
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.locals.value -
    birthNotice.pregnancy.prenatalMonitorizationFulfillment.locals.reason -
    birthNotice.pregnancy.PregnancyType Observation[Pregancy].component
    birthNotice.pregnancy.twinNumber Observation[Pregancy].component
    birthNotice.birth.date Observation[Birth].effectiveDatetime
    birthNotice.birth.type Observation[Birth].component
    birthNotice.birth.participation Observation[Birth].component
    birthNotice.birth.reason Observation[Birth].component
    birthNotice.birth.assist Observation[Birth].component
    birthNotice.birth.assistDescription Observation[Birth].component
    birthNotice.puerperium.type Observation[puerperium]
    birthNotice.puerperium.observations Observation[puerperium]
    birthNotice.newborn.liveBirth Patient[Child].deceased
    birthNotice.newborn.gender Patient[Child].gender
    birthNotice.newborn.length Observation[length]
    birthNotice.newborn.deceased Patient[Child].deceased
    birthNotice.newborn.deathBirth Patient[Child].deceased
    birthNotice.newborn.deathBirthDate Patient[Child].deceased
    birthNotice.newborn.reanimated -
    birthNotice.newborn.cephalicPerimeter Observation[cephalicPerimeter]
    birthNotice.newborn.weight Observation[weight]
    birthNotice.newborn.apgarIndexFirstMinute Observation[apgarScore]
    birthNotice.newborn.apgarIndexFifthMinute Observation[apgarScore]
    birthNotice.newborn.apgarIndexTenthMinute Observation[apgarScore]
    birthNotice.newborn.phototherapy Observation[phototherapy]
    birthNotice.newborn.malformations.code Observation[malformation]
    birthNotice.newborn.malformations.description Observation[malformation]
    birthNotice.newborn.AdmissionNeonatology Encounter.class
    birthNotice.newborn.AdmissionNeonatologyReason Encounter.reasonCode
    birthNotice.newborn.AdmissionNeonatologyLocal Encounter.location
    birthNotice.newborn.transport.Neonatal Basic
    birthNotice.newborn.transport.NeonatalDestination Basic
    birthNotice.newborn.transport.NeonatalReason Basic
    birthNotice.newborn.transport.InUtero Basic
    birthNotice.newborn.transport.InUteroProvanance Basic
    birthNotice.newborn.transport.InUteroReason Basic
    birthNotice.newborn.screeningMetabolicDiseasesTaken Observation[metabolic]
    birthNotice.newborn.screeningMetabolicReason Observation[metabolic]
    birthNotice.newborn.screeningMetabolicDiseasesDate Observation[metabolic]
    birthNotice.newborn.screeningCongenitalDiseases Observation[congenital]
    birthNotice.newborn.screeningCongenitalDiseasesChange Observation[congenital]
    birthNotice.newborn.screeningCongenitalDiseasesObservations Observation[congenital]
    birthNotice.newborn.screeningpupillaryReflection Observation[pupillary]
    birthNotice.newborn.screeningpupillaryReflectionChange Observation[pupillary]
    birthNotice.newborn.screeningpupillaryReflectionObservations Observation[pupillary]
    birthNotice.newborn.screeningHearing.type Observation[hearingscreen]
    birthNotice.newborn.screeningHearing.date Observation[hearingscreen]
    birthNotice.newborn.screeningHearing.rightEar Observation[hearingscreen]
    birthNotice.newborn.screeningHearing.leftEar Observation[hearingscreen]
    birthNotice.newborn.screeningHearing.repeatDate -
    birthNotice.newborn.VHB.taken Vaccination.status
    birthNotice.newborn.VHB.date Vaccination.occurrenceDateTime
    birthNotice.newborn.VHB.lot Vaccination.lotNumber
    birthNotice.newborn.VHB.reason Vaccination.statusReason
    birthNotice.newborn.BCG.taken Vaccination.status
    birthNotice.newborn.BCG.date Vaccination.occurrenceDateTime
    birthNotice.newborn.BCG.lot Vaccination.lotNumber
    birthNotice.newborn.BCG.reason Vaccination.statusReason
    birthNotice.newborn.immunoglobulin.taken Vaccination.status
    birthNotice.newborn.immunoglobulin.date Vaccination.occurrenceDateTime
    birthNotice.newborn.immunoglobulin.lot Vaccination.lotNumber
    birthNotice.newborn.immunoglobulin.reason Vaccination.statusReason
    birthNotice.newborn.feedingUntilDischarge Observation[Birth].component
    birthNotice.newborn.feedingFirstHour Observation[Birth].component
    birthNotice.newborn.individualHealthBulletinDelivered bulletindelivery
    birthNotice.newborn.childYoungHealthBulletinDelivered bulletindelivery
    birthNotice.newborn.bulletinDeliveryType bulletindelivery
    birthNotice.newborn.riskAssessment.riskFactorsIdentified Observation[newbornriskassessment].code
    birthNotice.newborn.riskAssessment.reference Observation[newbornriskassessment].extension
    birthNotice.newborn.riskAssessment.observations Observation[newbornriskassessment].note
    birthNotice.newborn.Outpatient.institution Encounter
    birthNotice.newborn.Outpatient.date Encounter
    birthNotice.newborn.confirmedDeceased Patient[child]
    birthNotice.puerperiumReview Observation[puerperium].performer
    birthNotice.childHealthSurveillance Organization
    birthNotice.letterWithClinicalInformation.hasLetterWithClinicalInformation Observation[letter]
    birthNotice.letterWithClinicalInformation.date Observation[letter]
    birthNotice.professionals Practitioner

Estrutura FHIR

Sendo um documento, os recursos estão organizados de maneira a tentar estar agrupados de maneira lógica. O recurso Bundle atua como o envelope do documento todo. O recurso Composition é o principal ponte para conseguir entender a organização lógica. O perfil está aqui e visualmente poderá ser entendido como:

CompositionSection motherInformação sobre a gravidezSection birthInformação sobre o parto, assim como episódiosSection newbornInformação sobre o(s) recém-nascido(s)Section examsInformação sobre exames, análises laboratoriais e avaliaçõesSection vaccinationInformação sobre vacinaçãoSection followupInformação sobre follow-up, próximos passosSection destinationInformação sobre destinos alta