# BR.GOV.SAUDE.BR-CORE.FHIR\Registro de Atendimento Clínico - FHIR v4.0.1

* [**Table of Contents**](toc.md)
* [**Lista de artefatos**](artifacts.md)
* **Registro de Atendimento Clínico**

## Example Composition: Registro de Atendimento Clínico

| |
| :--- |
|  |

**status**: Final

**type**: Nota de consulta

**category**: Nota de consulta

**encounter**: [Ambulatorial](Encounter-c6d553d8-cce0-404b-9d1f-eeffbf7fc6df.md)

**date**: 2024-12-19 14:30:00+0000

**author**: [Maria Clara](Practitioner-d3b61455-f432-48f0-b83b-ba825922d735.md)

**title**: Registro de Atendimento Clínico



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "7681618d-399d-4291-b321-32ce6d645088",
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "11488-4",
      "display" : "Consult note"
    }],
    "text" : "Nota de consulta"
  },
  "category" : [{
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "11488-4",
      "display" : "Consult note"
    }],
    "text" : "Nota de consulta"
  }],
  "subject" : {
    "reference" : "Patient/b2f63a4c-ddaa-4652-8481-ac1ff473104e",
    "display" : "João Carlos Silva"
  },
  "encounter" : {
    "reference" : "Encounter/c6d553d8-cce0-404b-9d1f-eeffbf7fc6df",
    "display" : "Ambulatorial"
  },
  "date" : "2024-12-19T14:30:00Z",
  "author" : [{
    "reference" : "Practitioner/d3b61455-f432-48f0-b83b-ba825922d735",
    "display" : "Maria Clara"
  }],
  "title" : "Registro de Atendimento Clínico",
  "section" : [{
    "title" : "Diagnósticos Avaliados",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "57852-6",
        "display" : "Problem list Reported"
      }],
      "text" : "Lista de Problemas - Diagnósticos Avaliados"
    },
    "entry" : [{
      "reference" : "Condition/91d8d24f-a70d-4ebf-8dea-71cf92ce1bd5",
      "display" : "Dispnéia"
    }]
  },
  {
    "title" : "Procedimentos Realizados",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "47519-4",
        "display" : "Procedures Hx Doc"
      }],
      "text" : "Procedimentos Realizados"
    },
    "entry" : [{
      "reference" : "Procedure/b0030c23-bd7d-445e-bfe5-020828f7dbaf",
      "display" : "Consulta médica em atenção primária"
    }]
  },
  {
    "title" : "Sinais Vitais",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "85354-9",
        "display" : "Blood pressure panel with all children optional"
      }]
    },
    "entry" : [{
      "reference" : "Observation/07ce5462-f77b-4ad6-af8c-2f67a6500b97",
      "display" : "Vital Signs"
    }]
  },
  {
    "title" : "Alergias e Intolerâncias",
    "code" : {
      "coding" : [{
        "system" : "https://terminologia.saude.gov.br/fhir/CodeSystem/BRAlergenosCBARA",
        "code" : "amendoim",
        "display" : "Amendoim"
      }]
    },
    "entry" : [{
      "reference" : "AllergyIntolerance/42a8e4ee-cc8b-4c07-bee2-da8fe14ada34",
      "display" : "Allergy Intolerance"
    }]
  },
  {
    "title" : "Medicamentos",
    "code" : {
      "coding" : [{
        "system" : "http://www.whocc.no/atc",
        "code" : "J01MA12",
        "display" : "levofloxacino"
      }]
    },
    "entry" : [{
      "reference" : "Medication/3a46210c-7eb3-48ec-aa67-db7e7ee18864",
      "display" : "Medication"
    }]
  },
  {
    "title" : "Plano de Cuidados",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "18776-5",
        "display" : "Plan of care note"
      }]
    },
    "entry" : [{
      "reference" : "CarePlan/1ed343f2-5231-40d6-a6ea-4428105b7532",
      "display" : "CarePlan"
    }]
  }]
}

```
