HL7 PT FHIR Implementation Guide: Noticia de Nascimento
1.0.0 - STU1
HL7 PT FHIR Implementation Guide: Noticia de Nascimento
1.0.0 - STU1
HL7 PT FHIR Implementation Guide: Noticia de Nascimento, publicado por HL7 Portugal. Este guia não é uma publicação autorizada; é a compilação contínua para a versão 1.0.0 construída pela FHIR (HL7® FHIR® Standard) CI Build. Esta versão é baseada no conteúdo atual de https://github.com/hl7-pt/obs-neonat-ig/ e muda regularmente. Veja o Diretório de versões publicadas
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[GestationalAge].valueQuantity (UCUM d) |
||
| birthNotice.pregnancy.weeks | Observation[GestationalAge].valueQuantity (UCUM wk) |
||
| 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[BirthLength] | ||
| 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[BirthHeadCircumference] | ||
| birthNotice.newborn.weight | Observation[BirthWeight] | ||
| 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 | ServiceRequest[screeningRequest].occurrenceDateTime | ||
| 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].effectiveDateTime / ServiceRequest[screeningRequest].occurrenceDateTime | ||
| 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 |
Os campos puerperiumReview.local e childHealthSurveillance.local do formulário da norma mapeiam para Organization.type (perfil HealthcareOrganization), com o value set TipoLocalSeguimentoVS:
| Valor no formulário | Código SNOMED CT | Designação (pt-PT) | Notas |
|---|---|---|---|
| USF/UCSP | 45131006 | Cuidados de saúde primários | |
| No Hospital | 224885007 | Consulta hospitalar | A vigilância em contexto hospitalar ocorre em consulta externa |
| Privado | — | — | Sem correspondência adequada. A distinção público/privado corresponde ao setor do prestador e não ao tipo de local; a sua representação num elemento próprio está em avaliação. O conceito 309895006 (Hospital privado) não é usado por ser demasiado restritivo (o seguimento privado ocorre frequentemente em consultório ou clínica) |
| Outro | — | — | Registar em type.text |
| Não sabe | — | — | Ausência de informação, não um tipo de local: registar com a extensão data-absent-reason (unknown) em type |
| (não previsto na norma) | 1367626006 | Seguimento no estrangeiro | Para os casos em que a família passa a residir fora do país |
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: