Narrativa gerada: StructureDefinition CCUC1DE82 Nome Bandeiras Card. Tipo Descrição e condicionalismos<img src="[binary]" alt="doco" style="background-color: inherit"/> Observation 0..* BRCoreObservation Measurements and simple assertions #xD; code S 1..1 CodeableConcept Código da observação Padrão necessário: Pelo menos os seguintes elementos #xD; coding 1..* Coding Code defined by a terminology system Valor fixo: (complexo) #xD; system 1..1 uri Identity of the terminology system Valor fixo: https://mangara.hsl.org.br/fhir/CodeSystem/CCUC1DE82 #xD; code 1..1 code Symbol in syntax defined by the system Valor fixo: CCUC1DE82 #xD; display 1..1 string Representation defined by the system Valor fixo: Observações sobre o laudo da colposcopia #xD; value[x] S 1..1 string Observações sobre o laudo da colposcopia Vínculo: https://mangara.hsl.org.br/fhir/ValueSet/CCUC1DE83 (required) #xD; <img src="[binary]" alt="doco" style="background-color: inherit"/> Documentação para este formato
CCU.C1.DE82 - Observações sobre o laudo da colposcopia
CCU.C1.DE82 - Informa observações adicionais sobre o laudo da colposcopia.
Measurements and simple assertions made about a patient, device or other subject.
Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
dataAbsentReason SHALL only be present if Observation.value[x] is not present
dataAbsentReason.empty() or value.empty()
not(exists(f:dataAbsentReason)) or (not(exists(*[starts-with(local-name(.), 'value')])))
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()
not(f:*[starts-with(local-name(.), 'value')] and (for $coding in f:code/f:coding return f:component/f:code/f:coding[f:code/@value=$coding/f:code/@value] [f:system/@value=$coding/f:system/@value]))
Observation[classCode=OBS, moodCode=EVN]
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Um conjunto de regras sob as quais este conteúdo foi criado
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.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Resumo do texto do recurso em linguagem natural
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.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Extensões adicionais que não fazem parte do modelo base
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Identificadores externos para este recurso
Allows observations to be distinguished and referenced.
OBX.21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 2) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4.
Referência ao pedido ou ao plano de tratamento que gerou este recurso
Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.
Referência ao evento do qual este recurso faz parte
To link an Observation to an Encounter use `encounter`. See the [Notes](http://hl7.org/fhir/R4/observation.html#obsgrouping) below for guidance on referencing another Observation.
active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Need to track the status of individual results. Some results are finalized before the whole report is finalized.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Codes providing the status of an observation.
status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of "revise"
In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set.
Used for filtering what observations are retrieved and displayed.
Codes for high level observation categories.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
*All* code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.
Knowing what kind of observation is being made is essential to understanding the observation.
Observações sobre o laudo da colposcopia
Codes identifying names of simple observations.
< 363787002 |Observable entity| OR < 386053000 |Evaluation procedure|
Referência ao paciente ou local ou dispositivo ou grupo desta bservação
One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated.
Observations have no value if you don't know who or what they're about.
ID exclusivo para referência entre elementos
Extensions are always sliced by (at least) url
Conteúdo adicional definido por implementações
Referência literal, URL relativa, interna ou absoluta
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.
Tipo de referência (por exemplo, Paciente)
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Referência lógica, quando a referência literal não é conhecida
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Referência à outro recurso desta observação
Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use `specimen` if a reference to a specimen is required. If a code is required instead of a resource use either `bodysite` for bodysites or the standard extension [focusCode](http://hl7.org/fhir/R4/extension-observation-focuscode.html).
Referência ao atendimento durante o qual esta observação foi registrada
This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
For some observations it may be important to know the link between an observation and a particular encounter.
inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Tempo ou período de tempo clinicamente relevante para a observação
At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the [Timing](http://hl7.org/fhir/R4/datatypes.html#timing) datatype which allow the measurement to be tied to regular life events.
Knowing when an observation was deemed true is important to its relevance as well as determining trends.
OBX-14, and/or OBX-19 after v2.4 (depends on who observation made)
Data/hora em que esta versão foi disponibilizada
For Observations that don’t require review and verification, it may be the same as the [`lastUpdated` ](http://hl7.org/fhir/R4/resource-definitions.html#Meta.lastUpdated) time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the `lastUpdated` time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again.
OBR.22 (or MSH.7), or perhaps OBX-19 (depends on who observation made)
Referência ao responsável pela observação
May give a degree of confidence in the observation and also indicates where follow-up questions should be directed.
OBX.15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO'
Informa observações adicionais sobre o laudo da colposcopia.
An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section](http://hl7.org/fhir/R4/observation.html#notes) below.
An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.
Utilizado para especificar o porquê o valor esperado não está presente
Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory". The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values.
For many results it is necessary to handle exceptional values in measurements.
Codes specifying why the result (`Observation.value[x]`) is missing.
Interpretação da observação. Por exemplo: valor alto, baixo, normal
Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result.
For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result.
Codes identifying interpretations of observations.
May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
Need to be able to provide free text additional information.
NTE.3 (partner NTE to OBX, or sometimes another (child?) OBX)
Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension[ bodySite](http://hl7.org/fhir/R4/extension-bodysite.html).
Codes describing anatomical locations. May include laterality.
Only used if not implicit in code for Observation.code.
In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results.
Should only be used if not implicit in code found in `Observation.code`. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report).
Dispositivo utilizado para registrar esta observação
Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.
Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts.
Must have at least a low or a high or text
low.exists() or high.exists() or text.exists()
(exists(f:low) or exists(f:high)or exists(f:text))
outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]
Identificador único para referência cruzada
Extensões adicionais que não fazem parte do modelo de dados básico
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Limite inferior do intervalo de valores de referência
Limite superior do intervalo de valores de referência
This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed.
Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation.
Code for the meaning of a reference range.
< 260245000 |Findings values| OR < 365860008 |General clinical state finding| OR < 250171008 |Clinical history or observation findings| OR < 415229000 |Racial group| OR < 365400002 |Finding of puberty stage| OR < 443938003 |Procedure carried out on subject|
This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed.
Need to be able to identify the target population for proper interpretation.
Codes identifying the population the reference range applies to.
Intervalo de referência em formato textual
Referência à Observação/Resposta de questionário associada a esta observação
When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see [Notes](http://hl7.org/fhir/R4/observation.html#obsgrouping) below. Note that a system may calculate results from [QuestionnaireResponse](http://hl7.org/fhir/R4/questionnaireresponse.html) into a final score and represent the score as an Observation.
Relationships established by OBX-4 usage
Referência à Documents, Imagens, Mídias associadas a esta observação
All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see [Notes](http://hl7.org/fhir/R4/observation.html#obsgrouping) below.
For a discussion on the ways Observations can be assembled in groups together see [Notes](http://hl7.org/fhir/R4/observation.html#notes) below.
Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation.
Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas
*All* code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation.
Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the [Notes section](http://hl7.org/fhir/R4/observation.html#notes) below.
363714003 |Interprets| < 441742003 |Evaluation finding|
Por que o resultado do componente está ausente
"Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done". The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values.
Interpretação do resultado do componente
Valores de referência para auxiliar na interpretação do resultado