Guia de implementação do Sumário Internacional do Paciente: Release 1 - BR Realm | STU1
1.0.0 - STU1 Brazil flag

This page is part of the IPS Brasil (v1.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example Bundle: Exemplo de IPS Brasileiro.


Document Subject

A ser enriquecido pelo CADSUS (sem género declarado), DoB: ( http://rnds.saude.gov.br/fhir/r4/NamingSystem/cpf#12345678901)



Document Content

Title: International Patient Summary from Brazil, code: http://loinc.org#60591-5, status: generated, confidentiality: N

Section Problems

Lista de problemas de saúde atuais e passados do paciente.

Current Medication

Lista de medicamentos que o paciente está utilizando atualmente.

Allergies and Intolerances

Registro de alergias e intolerâncias do paciente, incluindo alergia à penicilina.

Results

Resultados de exames laboratoriais e diagnósticos relevantes.

Immunizations

Histórico de imunizações recebidas pelo paciente.

History of procedures

Histórico de procedimentos realizados pelo paciente, incluindo consultas e intervenções médicas.

Recursos adicionais incluídos no documento


Entrada 2 - fullUrl = urn:uuid:31024c66-483a-4c80-b182-157ee133ca96

Recurso Organization:

identifier: http://rnds.saude.gov.br/fhir/r4/NamingSystem/cnes/7654321

name: Consultório Dr. José Silva


Entrada 3 - fullUrl = urn:uuid:498615d6-279f-4883-b4e2-e32f86f75aa1

Recurso AllergyIntolerance:

clinicalStatus: Active

code: No information about allergies

patient: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 4 - fullUrl = urn:uuid:b1997888-85fd-41b6-bf94-6242cf3c8265

Recurso Patient:

A ser enriquecido pelo CADSUS (sem género declarado), DoB: ( http://rnds.saude.gov.br/fhir/r4/NamingSystem/cpf#12345678901)



Entrada 5 - fullUrl = urn:uuid:c5771fd6-63a6-4a3b-936c-22146d2be9d5

Recurso Condition:

clinicalStatus: Active

verificationStatus: Confirmed

code: Diabetes mellitus tipo 2 não controlada

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 6 - fullUrl = urn:uuid:40386463-e1c7-46d4-92c7-b65ace40fa41

Recurso MedicationStatement:

status: recorded

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

dosage

text: 10 mg/day

timing: Uma vez por 1 day

DoseAndRates

-Dose[x]
*10 mg (Detalhes: UCUM códigomg = 'mg')

Entrada 7 - fullUrl = urn:uuid:3ece2664-c963-4627-9592-16e524706929

Recurso Observation:

status: Final

category: Laboratory

code: Hemoglobina

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

effective: 2025-04-02 10:36:48-0300

performer: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 8 - fullUrl = urn:uuid:5aaaf460-6fc0-4097-9e05-574367284450

Recurso Observation:

status: Final

category: Laboratory

code: Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

effective: 2020-04-22 19:20:00+0200

performer: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 9 - fullUrl = urn:uuid:14d1729d-16c7-45a2-be7f-bc17f261ce85

Recurso Observation:

status: Final

category: Vital Signs

code: Temperatura Corporal

subject: Ana Beatriz Oliveira

effective: 2025-04-03 16:50:39-0300

issued: 2025-04-03 16:55:39-0300

performer: Maria Clara

value: 36.5 °C (Detalhes: UCUM códigoCel = 'Cel')

interpretation: Normal

bodySite: Oral cavity

method: Oral temperature taking

ReferenceRanges

-LowHigh
*36.1 °C (Detalhes: UCUM códigoCel = 'Cel')37.2 °C (Detalhes: UCUM códigoCel = 'Cel')

Entrada 10 - fullUrl = urn:uuid:12813e0a-e0f8-4318-9e2a-2eced2470876

Recurso Observation:

status: Final

category: Imaging

code: CT Abdomen W contrast IV

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

effective: 1995-06-08

performer: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 11 - fullUrl = urn:uuid:bebecb29-e907-4d6f-9690-c82ca7e1ae55

Recurso Observation:

status: Final

category: Vital Signs

code: Perceived stress scale-10 [PSS-10]

subject: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

effective: 2025-04-03 10:00:00-0300

performer: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000


Entrada 12 - fullUrl = urn:uuid:714819de-cd07-4423-94ea-7057504a2cc8

Recurso Immunization:

status: Completed

vaccineCode: Vacina gripe sazonal

lotNumber: 12345AB

expirationDate: 2024-12-31

patient: Bundle: identifier = UUID:234c1054-83a7-4adf-9387-b673b96664d5; type = document; timestamp = 2025-05-09 15:27:33+0000

occurrence: 2024-06-01 14:30:00+0000

primarySource: true

site: Glúteo máximo

route: intramusculuar

doseQuantity: 0.3 mL (Detalhes: UCUM códigomL = 'mL')

Performers

-FunctionActor
*ENFERMEIROMaria Clara

ProtocolApplieds

-TargetDisease
*influenza

Entrada 13 - fullUrl = urn:uuid:d3b61455-f432-48f0-b83b-ba825922d735

Recurso Practitioner:

identifier: Número do Cartão Nacional de Saúde/987654321098765 (utilização: official, )

active: true

name: Maria Clara Oliveira (Official)

telecom: +55 21 98765-4321, maria.oliveira@example.com

address: Av. Central, 456, Bairro Centro, Rio de Janeiro, RJ, 20000-000(work)

Qualifications

-IdentifierCodePeriodIssuer
*https://saude.gov.br/fhir/sid/cns/225125789542376MEDICO CLINICO2010-01-01 --> (em curso)Consultório Dr. José Silva

Entrada 14 - fullUrl = urn:uuid:2d7b5358-19aa-4f21-b7c5-9260ed832c6c

Recurso Procedure:

status: Completed

category: Consulta

code: Consulta com clínico geral

subject: Ana Beatriz Oliveira

Performers

-Actor
*Dra. Maria Clara

outcome: Paciente estável e orientado

note:

Paciente orientado a manter dieta balanceada e atividade física regular.


Entrada 15 - fullUrl = urn:uuid:e8076935-bd85-4be3-a0a0-7349b972b130

Recurso Medication:

code: Loratadina 10 mg comprimido