Resumen Clínico de Paciente de Chile (IPS-CL)
0.2.0 - ci-build Chile flag

This page is part of the Resumen Clinico de Paciente de Chile (v0.2.0: STU1 Draft) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: Documento (IPS-CL)

Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Composition-cl-ips Version: 0.2.0
Standards status: Draft Maturity Level: 1 Computable Name: DocumentoClIps

Copyright/Legal: HL7 International

Documento clínico utilizado para representar el conjunto de datos del Resumen Internacional de Pacientes (IPS). Un documento de Resumen Internacional de Paciente (IPS) es un extracto de historia clínica electrónica que contiene información sanitaria esencial sobre un sujeto de atención. El conjunto de datos IPS es mínimo y no exhaustivo; independiente de la especialidad y la afección; pero sigue siendo clínicamente relevante. Tal como se especifica en las normas EN 17269 e ISO 27269, está diseñado para apoyar el caso de uso de la «atención transfronteriza no planificada», pero no se limita a él. Pretende ser internacional, es decir, ofrecer soluciones genéricas para su aplicación global más allá de una región o país concretos.

Este perfil se basa en el perfil ClinicalDocument.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition International Patient Summary Documento
... text S 0..1 Narrative Text summary of the resource, for human interpretation
... identifier S 0..1 Identifier Version-independent identifier for the Composition
... status S 1..1 code preliminary | final | amended | entered-in-error
.... 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: 60591-5
... subject S 1..1 Reference(Paciente (IPS-CL)) Who and/or what the composition is about
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... date S 1..1 dateTime Composition editing time
... author S 1..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Quién y/o qué fue el autor del IPS
... title S 1..1 string International Patient Summary Genérico para uso en Chile
... attester S 0..* BackboneElement Attests to accuracy of composition
.... mode S 1..1 code personal | professional | legal | official
.... time S 0..1 dateTime When the composition was attested
.... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian S 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition | Documento (IPS-CL))
... Slices for event 0..* BackboneElement The clinical service(s) being documented
Slice: Unordered, Open by pattern:code
.... event:careProvisioningEvent S 0..1 BackboneElement La asistencia descrita en el documento
..... code S 1..1 CodeableConcept Code(s) that apply to the event being documented
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/v3-ActClass
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: PCPR
..... period S 0..1 Period The period covered by the documentation
... Slices for section S 3..* BackboneElement Secciones que componen el IPS
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
..... text S 1..1 Narrative Text summary of the section, for human interpretation
..... emptyReason 0..0
..... section 0..0
.... section:sectionMedicamentos S 1..1 BackboneElement Sección de Resumen de Medicamentos IPS
..... title S 1..1 string Sección de Resumen de Medicamentos
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 10160-0
..... Slices for entry S 1..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medicamentos relevantes para la salud del paciente
Slice: Unordered, Open by profile:resolve()
...... entry:listMedicamentos 0..* Reference(Declaración de medicación (IPS-CL)) A reference to data that supports this section
...... entry:prescripciones 0..* Reference(Solicitud de medicación (IPS-CL)) A reference to data that supports this section
.... section:sectionAlergias S 1..1 BackboneElement Sección de Alergias e Intolerancias
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 48765-2
..... Slices for entry S 1..* Reference(AllergyIntolerance | DocumentReference) Alergias o intolerancias (afecciones) relevantes para ese paciente.
Slice: Unordered, Open by profile:resolve()
...... entry:alergias S 1..* Reference(Alergias e Intolerancias (IPS-CL)) A reference to data that supports this section
.... section:sectionProblemas S 1..1 BackboneElement Problemas de Salud
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 11450-4
..... Slices for entry S 1..* Reference(Condition | DocumentReference) Problemas o afecciones clínicas que se están controlando actualmente en el paciente.
Slice: Unordered, Open by profile:resolve()
...... entry:problema S 1..* Reference(Condición (IPS-CL)) A reference to data that supports this section
.... section:sectionProcedimientos S 0..1 BackboneElement Historial de Procedimientos
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 47519-4
..... Slices for entry S 1..* Reference(Procedure | DocumentReference) Procedimientos anteriores del paciente pertinentes para el ámbito de este documento.
Slice: Unordered, Open by profile:resolve()
...... entry:procedimiento S 1..* Reference(Procedimientos (IPS-CL)) A reference to data that supports this section
.... section:sectionImmunizaciones S 0..1 BackboneElement Sección de Inmunizaciones
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 11369-6
..... Slices for entry S 1..* Reference(Immunization | DocumentReference) Estado de vacunación del paciente y antecedentes pertinentes.
Slice: Unordered, Open by profile:resolve()
...... entry:immunizacion S 1..* Reference(Immunización (IPS-CL)) A reference to data that supports this section
.... section:sectionDispMedicos S 0..1 BackboneElement Sección de Dispositivos Médicos
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 46264-8
..... Slices for entry S 1..* Reference(DeviceUseStatement | DocumentReference) La historia de dispositivos médicos en uso
Slice: Unordered, Open by profile:resolve()
...... entry:deviceStatement S 1..* Reference(Declaración de uso del dispositivo (IPS-CL)) A reference to data that supports this section
.... section:sectionResultados S 0..1 BackboneElement Sección de Resultados
..... title S 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 30954-2
..... Slices for entry S 1..* Reference(Observation | DiagnosticReport | DocumentReference) Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente.
Slice: Unordered, Open by type:resolve(), profile:resolve()
...... entry:resultados-obs-lab-pato S 0..* Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) A reference to data that supports this section
...... entry:resultados-obs-radio S 0..* Reference(Observación Resultado: Imagenológico (IPS-CL)) A reference to data that supports this section
...... entry:resultado-reporte S 0..* Reference(Reporte Diagnóstico (IPS-CL)) A reference to data that supports this section
.... section:sectionSignosVitales 0..1 BackboneElement Sección de Signos Vitales
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 8716-3
..... Slices for entry 0..* Reference(Observation | DocumentReference) Signos vitales o hallazgos físicos de interés.
Slice: Unordered, Open by profile:resolve()
...... entry:vitalSign 0..* Reference(Vital Signs Profile) A reference to data that supports this section
.... section:sectionHistoricoHx 0..1 BackboneElement Histórico de enfermedades
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 11348-0
..... Slices for entry 1..* Reference(Condition | DocumentReference) Condiciones sufridas por el paciente en el pasado
Slice: Unordered, Open by profile:resolve()
...... entry:pastProblem 1..* Reference(Condición (IPS-CL)) A reference to data that supports this section
.... section:sectionStatusFuncional 0..1 BackboneElement Status Funcional
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 47420-5
..... Slices for entry 0..* Reference(Condition | ClinicalImpression | DocumentReference) Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales
Slice: Unordered, Open by profile:resolve()
...... entry:discapacidad 0..* Reference(Condición (IPS-CL)) A reference to data that supports this section
...... entry:evalFuncional 0..* Reference(ClinicalImpression) A reference to data that supports this section
.... section:sectionPlanCuidado 0..1 BackboneElement Plan de Cuidado
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 18776-5
..... Slices for entry 0..* Reference(CarePlan | DocumentReference) Resumen de plan de cuidados
Slice: Unordered, Open by profile:resolve()
...... entry:carePlan 0..* Reference(CarePlan) A reference to data that supports this section
.... section:sectionHistoriaSocial 0..1 BackboneElement Historia Social
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 29762-2
..... Slices for entry 0..* Reference(Observation | DocumentReference) Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.)
Slice: Unordered, Open by profile:resolve()
...... entry:fumador 0..1 Reference(Observación - SH: Uso de tabaco (IPS CL)) A reference to data that supports this section
...... entry:alcohol 0..1 Reference(Observación - SH: Uso de Alcohol (IPS CL)) A reference to data that supports this section
.... section:sectionEmbarazoHx 0..1 BackboneElement Historial de Embarazos
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 10162-6
..... Slices for entry 0..* Reference(Observation | DocumentReference) Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores.
Slice: Unordered, Open by profile:resolve()
...... entry:statusEmbarazo 0..* Reference(Observación - Embarazo: Estado (IPS-CL)) A reference to data that supports this section
...... entry:resultadoEmbarazo 0..* Reference(Observación - Embarazo: Resultados (IPS-CL)) A reference to data that supports this section
.... section:sectionFlagAlerts 0..1 BackboneElement Flag - Alertas
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 104605-1
..... Slices for entry 0..* Reference(Flag | DocumentReference) Información sobre alertas relacionadas al paciente.
Slice: Unordered, Open by profile:resolve()
...... entry:alertsFlag 0..* Reference(Flag - Alerta (IPS-CL)) A reference to data that supports this section
.... section:sectionDirectivasAvanzadas 0..1 BackboneElement Sección de Consentimientos
..... title 1..1 string Label for section (e.g. for ToC)
..... code 0..1 CodeableConcept Classification of section (recommended)
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: 42348-3
..... Slices for entry 0..* Reference(Consent | DocumentReference) Descripción narrativa del documento de declaraciones de acceso del paciente.
Slice: Unordered, Open by profile:resolve()
...... entry:advanceDirectivesConsent 0..* Reference(Consent) A reference to data that supports this section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron