Guía implementación interoperabilidad FHIR sectorial e intersectorial
0.14.0 - ci-build

Guía implementación interoperabilidad FHIR sectorial e intersectorial - Local Development build (v0.14.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: Consulta Externa - Registro clínico - Examen físico - XML Representation

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<Observation xmlns="http://hl7.org/fhir">
  <id value="Example-CE-Observation-e8021b2484"/>
  <meta>
    <profile
             value="https://ohapi-fhir-dev-service-fhir-project.apps.indraclusterdes.eastus.aroapp.io/StructureDefinition-ProfileObservationHCEU"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Observation Example-CE-Observation-e8021b2484</b></p><a name="Example-CE-Observation-e8021b2484"> </a><a name="hcExample-CE-Observation-e8021b2484"> </a><a name="Example-CE-Observation-e8021b2484-es-ES"> </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-ProfileObservationHCEU.html">HCEU - Intramural - Observation</a></p></div><p><b>identifier</b>: <code>http://hospitalSystemInformation.example.org/observations/</code>/observation-ce-012 (use: usual, )</p><p><b>status</b>: Final</p><p><b>code</b>: <span title="Codes:{https://loinc.org 29545-1}">Physical findings Narrative</span></p><p><b>subject</b>: <a href="Patient-Example-CE-Patient-352d698c8230.html">Paola Andrea Torres Ramirez(official) Female, DoB: 1988-06-23 ( Medical record number: 36423902344 (use: usual, ))</a></p><p><b>encounter</b>: <a href="Encounter-Example-CE-Encounter-6bf8f5968a20.html">Encounter: extension = Demanda espontánea (Vías de ingreso#01); identifier = http://hospitalSystemInformation.example.org/admissions#ENC-001 (use: usual, ); status = finished; class = Consulta Externa (ActCode#AMB); serviceType = GENERAL ADULTOS; period = 2025-04-14 09:00:00+0000 --&gt; 2025-04-14 09:30:00+0000</a></p><p><b>effective</b>: 2025-03-18 07:55:00+0000 --&gt; 2025-03-18 08:05:00+0000</p><p><b>issued</b>: 2025-03-18 08:05:00+0000</p><p><b>performer</b>: <a href="Practitioner-Example-CE-Practitioner-7ca0b887ef05.html">Practitioner Felipe Andrés Camargo Parada(official)</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 32434-3}">General appearance</span></p><p><b>value</b>: Paciente luce una condición normal en la revisión básica de salud</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 71390-9}">CMS - head and face exam panel</span></p><p><b>value</b>: El paciente presenta resequedad severa en el cuero cabelludo</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org LP149251-3}">CMS - neck exam panel</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 57045-7}">Cardiac status</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es I49.9}">Cardiac arrhythmia, unspecified</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 52485-0}">Pulmonary Function Test</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es J84.8}">other specified interstitial pulmonary diseases</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 80271-0}">Physical findings of Abdomen by Palpation</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 54535-0}">Genitourinary</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 8703-1}">Physical findings Extremities</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 0321-3}">Musculoskeletal assessment panel</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 5970-4}">central nervous system panel</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title="Codes:{https://loinc.org 80343-7}">Skin assessment [Interpretation]</span></p><p><b>value</b>: <span title="Codes:{https://icd.who.int/browse/2024-01/mms/es Z00.00}">evaluación médica general sin hallazgos anormales</span></p></blockquote></div>
  </text>
  <identifier>
    <use value="usual"/>
    <system
            value="http://hospitalSystemInformation.example.org/observations/"/>
    <value value="observation-ce-012"/>
  </identifier>
  <status value="final"/>
  <code>
    <coding>
      <system value="https://loinc.org"/>
      <code value="29545-1"/>
      <display value="Physical findings Narrative"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/Example-CE-Patient-352d698c8230"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/Example-CE-Encounter-6bf8f5968a20"/>
  </encounter>
  <effectivePeriod>
    <start value="2025-03-18T07:55:00Z"/>
    <end value="2025-03-18T08:05:00Z"/>
  </effectivePeriod>
  <issued value="2025-03-18T08:05:00Z"/>
  <performer>🔗 
    <reference value="Practitioner/Example-CE-Practitioner-7ca0b887ef05"/>
  </performer>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="32434-3"/>
        <display value="General appearance"/>
      </coding>
    </code>
    <valueString
                 value="Paciente luce una condición normal en la revisión básica de salud"/>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="71390-9"/>
        <display value="CMS - head and face exam panel"/>
      </coding>
    </code>
    <valueString
                 value="El paciente presenta resequedad severa en el cuero cabelludo"/>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="LP149251-3"/>
        <display value="CMS - neck exam panel"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="57045-7"/>
        <display value="Cardiac status"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="I49.9"/>
        <display value="Cardiac arrhythmia, unspecified"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="52485-0"/>
        <display value="Pulmonary Function Test"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="J84.8"/>
        <display value="other specified interstitial pulmonary diseases"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="80271-0"/>
        <display value="Physical findings of Abdomen by Palpation"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="54535-0"/>
        <display value="Genitourinary"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="8703-1"/>
        <display value="Physical findings Extremities"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="0321-3"/>
        <display value="Musculoskeletal assessment panel"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="5970-4"/>
        <display value="central nervous system panel"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
  <component>
    <code>
      <coding>
        <system value="https://loinc.org"/>
        <code value="80343-7"/>
        <display value="Skin assessment [Interpretation]"/>
      </coding>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="https://icd.who.int/browse/2024-01/mms/es"/>
        <code value="Z00.00"/>
        <display value="evaluación médica general sin hallazgos anormales"/>
      </coding>
    </valueCodeableConcept>
  </component>
</Observation>