From eb1acab6076f9ee369ffd75ae6b0f3ac350fc816 Mon Sep 17 00:00:00 2001 From: souadbenmustapha <121099321+souadbenmustapha@users.noreply.github.com> Date: Fri, 3 Oct 2025 11:47:22 +0200 Subject: [PATCH 1/2] =?UTF-8?q?Merge=20des=20aliases=20et=20pageContent=20?= =?UTF-8?q?dans=20la=20branche=20interm=C3=A9diaire=20(#57)?= MIME-Version: 1.0 Content-Type: text/plain; charset=UTF-8 Content-Transfer-Encoding: 8bit --- input/fsh/RessourcesFHIRCorps/aliases.fsh | 25 ++++++++++++++ input/pagecontent/ressourcesFHIR-corps.md | 41 +++++++++++++++++++++++ 2 files changed, 66 insertions(+) create mode 100644 input/fsh/RessourcesFHIRCorps/aliases.fsh diff --git a/input/fsh/RessourcesFHIRCorps/aliases.fsh b/input/fsh/RessourcesFHIRCorps/aliases.fsh new file mode 100644 index 0000000000..728fccff49 --- /dev/null +++ b/input/fsh/RessourcesFHIRCorps/aliases.fsh @@ -0,0 +1,25 @@ +// Extensions +Alias: $ihe-ext-medication-productname = https://profiles.ihe.net/PHARM/MPD/StructureDefinition/ihe-ext-medication-productname +Alias: $ihe-ext-medication-classification = https://profiles.ihe.net/PHARM/MPD/StructureDefinition/ihe-ext-medication-classification +Alias: $ihe-ext-medication-characteristic = https://profiles.ihe.net/PHARM/MPD/StructureDefinition/ihe-ext-medication-characteristic +Alias: $imposeProfile = http://hl7.org/fhir/StructureDefinition/structuredefinition-imposeProfile +Alias: $event-performerFunction = http://hl7.org/fhir/StructureDefinition/event-performerFunction +Alias: $workflow-supportingInfo = http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo +Alias: $bodySite = http://hl7.org/fhir/StructureDefinition/bodySite +Alias: $procedure-method = http://hl7.org/fhir/StructureDefinition/procedure-method + +// Code Systems +Alias: $LNC = http://loinc.org +Alias: $SCT = http://snomed.info/sct +Alias: $system = http://example.org/system +Alias: $v3-ActCode = http://terminology.hl7.org/CodeSystem/v3-ActCode +Alias: $CIM-10 = https://smt.esante.gouv.fr/terminologie-cim-10 +Alias: $CISP-2 = https://smt.esante.gouv.fr/terminologie-cisp +Alias: $CCAM = https://smt.esante.gouv.fr/terminologie-ccam +Alias: $SMS = https://smt.esante.gouv.fr/terminologie-sms +Alias: $terminologie-cisis = https://smt.esante.gouv.fr/fhir/CodeSystem/terminologie-cisis + +// JDVs +Alias: $jdv-hl7-v3-ActSubstanceAdministrationImmunizationCode-cisis = https://smt.esante.gouv.fr/fhir/ValueSet/jdv-hl7-v3-ActSubstanceAdministrationImmunizationCode-cisis +Alias: $jdv-absent-or-unknown-immunization-cisis = https://smt.esante.gouv.fr/fhir/ValueSet/jdv-absent-or-unknown-immunization-cisis +Alias: $jdv-immunization-route-code-cisis = https://smt.esante.gouv.fr/fhir/ValueSet/jdv-immunization-route-code-cisis diff --git a/input/pagecontent/ressourcesFHIR-corps.md b/input/pagecontent/ressourcesFHIR-corps.md index e69de29bb2..f255706d02 100644 --- a/input/pagecontent/ressourcesFHIR-corps.md +++ b/input/pagecontent/ressourcesFHIR-corps.md @@ -0,0 +1,41 @@ +### Liste des profils + +Cette page contient la liste des profils FHIR définis dans le guide **ANS IG Document Core**, utilisés pour l'implémentation de la partie corps des documents médicaux et médico-sociaux. + +{% sql { + "query": " + SELECT title AS Title, Description, Web + FROM Resources + WHERE Type = 'StructureDefinition' + AND ( + Title LIKE 'Observation%' + OR Title LIKE 'Condition%' + OR Title LIKE 'Specimen%' + OR Title LIKE 'Encounter%' + OR Title LIKE 'Device%' + OR Title LIKE 'Procedure%' + OR Title LIKE 'Medication%' + OR Title LIKE 'MedicationAdministration%' + OR Title LIKE 'MedicationRequest%' + OR Title LIKE 'AllergyIntolerance%' + OR Title LIKE 'MedicationDispense%' + OR Title LIKE 'ServiceRequest%' + OR Title LIKE 'Endpoint%' + OR Title LIKE 'CarePlan%' + OR Title LIKE 'Annotation%' + OR Title LIKE 'DocumentReference%' + OR Title LIKE 'FamilyMemberHistory%' + OR Title LIKE 'Consent%' + OR Title LIKE 'QuestionnaireResponse%' + OR Title LIKE 'AdverseEvent%' + OR Title LIKE 'DeviceRequest%' + OR Title LIKE 'DeviceUseStatement%' + OR Title LIKE 'DiagnosticReport%' + ) + ", + "class": "lines", + "columns": [ + { "title": "Titre du profil", "type": "link", "source": "Title", "target": "Web" }, + { "title": "Description", "type": "markdown", "source": "Description" } + ] +} %} \ No newline at end of file From 99c5f03e87b108288810d8f868d6009ac782aa6d Mon Sep 17 00:00:00 2001 From: Haoura Date: Fri, 17 Oct 2025 15:51:21 +0200 Subject: [PATCH 2/2] Ajout exemple IPS-FR --- input/fsh/Exemples-IPS-FR/document-IPS-FR.fsh | 1031 +++++++++++++++++ 1 file changed, 1031 insertions(+) create mode 100644 input/fsh/Exemples-IPS-FR/document-IPS-FR.fsh diff --git a/input/fsh/Exemples-IPS-FR/document-IPS-FR.fsh b/input/fsh/Exemples-IPS-FR/document-IPS-FR.fsh new file mode 100644 index 0000000000..a87f77b1d3 --- /dev/null +++ b/input/fsh/Exemples-IPS-FR/document-IPS-FR.fsh @@ -0,0 +1,1031 @@ +Instance: Bundle-IPS-FR +InstanceOf: Bundle +Usage: #example +* meta.lastUpdated = "2025-10-09T13:28:17.000+00:00" +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-bundle-document" +* identifier.system = "1.2.250.1.213.1.1.1.51.2024.1.1" +* identifier.value = "2024.01" +* type = #document +* timestamp = "2025-10-09T13:28:17.000+00:00" +* entry[0].fullUrl = "urn:uuid:09275181-4d85-43b8-89b0-6dd68182bc52" +* entry[=].resource = Composition-IPS-FR +* entry[+].fullUrl = "urn:uuid:00f54e2e-22f2-4162-87b4-4826d855feac" +* entry[=].resource = patientExemple +* entry[+].fullUrl = "urn:uuid:a11d31c5-77ff-4642-91f7-66c4d10d18c9" +* entry[=].resource = practitioner-role-exemple-1 +* entry[+].fullUrl = "urn:uuid:b5941194-08be-4893-a629-652f97587b39" +* entry[=].resource = practitioner-exemple-1 +* entry[+].fullUrl = "urn:uuid:579f1274-8265-4bb1-91ba-d093a11be4f5" +* entry[=].resource = organizationExemple +* entry[+].fullUrl = "urn:uuid:51807e91-cb17-4ca1-bc58-1efa85cf9d72" +* entry[=].resource = encounterExemple +* entry[+].fullUrl = "urn:uuid:648170b7-1538-44a7-8820-df04dcc32fad" +* entry[=].resource = locationExemple +* entry[+].fullUrl = "urn:uuid:257427f5-dffa-4a97-9475-4ebb988589af" +* entry[=].resource = Condition-Exemple-1 +* entry[+].fullUrl = "urn:uuid:4d6a4b74-b2a7-4ec1-8db1-8925f435a916" +* entry[=].resource = Condition-Exemple-2 +* entry[+].fullUrl = "urn:uuid:af0e13e5-d0a2-4dbc-b892-7328eca72ff4" +* entry[=].resource = Condition-Exemple-3 +* entry[+].fullUrl = "urn:uuid:a4d49149-cda7-470d-a2e3-08f8d7db1bad" +* entry[=].resource = Condition-Exemple-4 +* entry[+].fullUrl = "urn:uuid:803caba9-c128-4faa-94a0-d344738ebc63" +* entry[=].resource = Condition-Exemple-5 +* entry[+].fullUrl = "urn:uuid:effd6c8a-6122-46cb-82ed-ef3f300ec17b" +* entry[=].resource = Condition-Exemple-6 +* entry[+].fullUrl = "urn:uuid:18492799-4e37-47a7-b79b-18a4d0597963" +* entry[=].resource = Condition-Exemple-7 +* entry[+].fullUrl = "urn:uuid:4e00844f-241b-47c0-85a4-9d612c46b3ad" +* entry[=].resource = Procedure-Exemple-1 +* entry[+].fullUrl = "urn:uuid:5b0fcb3b-91fb-4870-bd97-8faa2794ea01" +* entry[=].resource = practitioner-role-exemple-2 +* entry[+].fullUrl = "urn:uuid:da9eb2be-5993-4e39-827b-728fe3943a93" +* entry[=].resource = organizationExemple2 +* entry[+].fullUrl = "urn:uuid:9e55af45-e661-472f-b713-4aaa2cfd1a77" +* entry[=].resource = practitioner-exemple-2 +* entry[+].fullUrl = "urn:uuid:be247a4c-f8fe-4224-b51c-8c35d7124a2d" +* entry[=].resource = Condition-Exemple-8 +* entry[+].fullUrl = "urn:uuid:3c6ec5d8-182d-4dfc-871b-59c9eb91aa51" +* entry[=].resource = Procedure-Exemple-2 +* entry[+].fullUrl = "urn:uuid:0ccf6c51-d3f5-4817-bc24-7f63a2ef3c7f" +* entry[=].resource = AllergieIntolerance-Exemple-1 +* entry[+].fullUrl = "urn:uuid:23f1c0a3-ce38-4817-9408-7feaeb04002d" +* entry[=].resource = EffetIndesirable-Exemple-1 +* entry[+].fullUrl = "urn:uuid:0409af90-4717-4a93-9800-fcf546875dc8" +* entry[=].resource = MedicationAdministration-Exemple-1 +* entry[+].fullUrl = "urn:uuid:f995f9bb-4043-45db-8b12-50dc7e9acc5a" +* entry[=].resource = Medication-Exemple-1 +* entry[+].fullUrl = "urn:uuid:a4e1cafa-05e4-40c7-82dc-641f54281671" +* entry[=].resource = Condition-Exemple-9 +* entry[+].fullUrl = "urn:uuid:1ff316e0-edde-4bb9-a5fe-822d486d8230" +* entry[=].resource = MedicationAdministration-Exemple-2 +* entry[+].fullUrl = "urn:uuid:fb88edae-4d3f-4b00-ae17-71c8f03adc71" +* entry[=].resource = Medication-Exemple-2 +* entry[+].fullUrl = "urn:uuid:034d19b3-3c4e-488a-a7c0-9181dfc721e3" +* entry[=].resource = DeviceUseStatement-Exemple-1 +* entry[+].fullUrl = "urn:uuid:7bb3e1f4-15bd-4c06-a587-3445c0f5a530" +* entry[=].resource = Device-Exemple-1 +* entry[+].fullUrl = "urn:uuid:41465f6b-d169-40b9-8d84-96064b4c3d28" +* entry[=].resource = DeviceUseStatement-Exemple-2 +* entry[+].fullUrl = "urn:uuid:f38b1772-ca78-4578-be14-f7a493b2cbb9" +* entry[=].resource = Device-Exemple-2 +* entry[+].fullUrl = "urn:uuid:960ebfbc-4b56-40b9-9990-cae5944d6e9b" +* entry[=].resource = Observation-Exemple1-Groupe-de-questionnaires-d-evaluation +* entry[+].fullUrl = "urn:uuid:e102b4b3-91b6-4b89-9065-560bc68c024c" +* entry[=].resource = Observation-Exemple-1-Evaluation +* entry[+].fullUrl = "urn:uuid:b9bca1ce-b850-408c-966c-26a1a87adf65" +* entry[=].resource = Observation-Exemple-2-Evaluation +* entry[+].fullUrl = "urn:uuid:ae1c9c50-9620-4755-a7a0-f72af5a82229" +* entry[=].resource = Observation-Exemple-3-Signe-vital-observe +* entry[+].fullUrl = "urn:uuid:44da5856-6555-4b43-b03f-176f45c29432" +* entry[=].resource = Observation-Exemple-4-Signe-vital-observe +* entry[+].fullUrl = "urn:uuid:48129cb5-0a81-4a17-aebd-8c6584b20cd4" +* entry[=].resource = Observation-Exemple-5-Habitus-Mode-De-Vie +* entry[+].fullUrl = "urn:uuid:3618f351-cea4-4834-8cf9-10151b74436b" +* entry[=].resource = Observation-Exemple-6-Habitus-Mode-De-Vie +* entry[+].fullUrl = "urn:uuid:4f0f3856-74a9-4a57-b173-e8342735d6c9" +* entry[=].resource = Observation-Exemple-7-Habitus-Mode-De-Vie +* entry[+].fullUrl = "urn:uuid:3799b968-d637-4a16-ad7b-5f79987dcdb1" +* entry[=].resource = Observation-Exemple-8-Habitus-Mode-De-Vie +* entry[+].fullUrl = "urn:uuid:541404fa-fc9c-4552-8d36-10adcc37f34e" +* entry[=].resource = FamilyMemberHistory-Exemple-1 +* entry[+].fullUrl = "urn:uuid:7f0d585b-9a48-4605-baab-30e93603a563" +* entry[=].resource = Immunizations-Exemple-1 +* entry[+].fullUrl = "urn:uuid:3a7417c1-d483-4f56-833d-43bf8e438874" +* entry[=].resource = Immunizations-Exemple-2 +* entry[+].fullUrl = "urn:uuid:f3062170-ef7b-45a7-802f-47e461a7d05d" +* entry[=].resource = practitioner-role-exemple-3 +* entry[+].fullUrl = "urn:uuid:4dbc2eff-6a94-4c7b-b49f-0f7a9790bef6" +* entry[=].resource = organization-Exemple-3 +* entry[+].fullUrl = "urn:uuid:ab96b0ff-374a-45c7-82e4-aaa8888a2fec" +* entry[=].resource = practitioner-exemple-3 +* entry[+].fullUrl = "urn:uuid:80c62f71-7c99-458d-884d-725bc410a14d" +* entry[=].resource = Condition-Exemple-10 +* entry[+].fullUrl = "urn:uuid:bea6c387-6dca-4f55-93b7-7079e1c88dfb" +* entry[=].resource = Observation-Exemple-8-sur-la-grossesse +* entry[+].fullUrl = "urn:uuid:bdc0e3ae-128b-46de-b1a7-1c564cca6a61" +* entry[=].resource = Observation-Exemple-9-sur-la-grossesse +* entry[+].fullUrl = "urn:uuid:e4299828-2563-4265-9297-c27a8240b6ba" +* entry[=].resource = Observation-Exemple-10-sur-la-grossesse +* entry[+].fullUrl = "urn:uuid:091bf5bc-2ed8-4328-a5e6-7d78aeeeb20b" +* entry[=].resource = Observation-Exemple-11-sur-la-grossesse +* entry[+].fullUrl = "urn:uuid:73af1b58-f567-4c03-a1a6-d65d3b3fd079" +* entry[=].resource = MedicationAdministration-Exemple-3 +* entry[+].fullUrl = "urn:uuid:83e3e384-84ca-46dd-aa8c-c847a70b1fb5" +* entry[=].resource = MedicationAdministration-Exemple-4 +* entry[+].fullUrl = "urn:uuid:2f861880-31d2-4969-a2ce-b78f750f430e" +* entry[=].resource = Medication-Exemple-3 +* entry[+].fullUrl = "urn:uuid:6349c4d2-bdba-41b1-b5d6-1ce8c359205d" +* entry[=].resource = Medication-Exemple-4 + +Instance: Composition-IPS-FR +InstanceOf: Composition +Usage: #inline +* meta.lastUpdated = "2025-09-09T13:28:17.000+00:00" +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-composition-document" +* language = #fr-FR +* extension.url = "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version" +* extension.valueString = "2" +* identifier.value = "1.2.250.1.213.1.1.1.51.2024.1" +* status = #final +* type = $loinc#60591-5 "Synthèse médicale" +* subject = Reference(urn:uuid:00f54e2e-22f2-4162-87b4-4826d855feac) +* encounter = Reference(urn:uuid:51807e91-cb17-4ca1-bc58-1efa85cf9d72) +* date = "2025-09-09T14:00:00+01:00" +* author.extension.url = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-author-time" +* author.extension.valueDateTime = "2024-04-21T13:45:00+01:00" +* author = Reference(urn:uuid:a11d31c5-77ff-4642-91f7-66c4d10d18c9) "DR Stéphane MEDIONI" +* title = "SYNTHESE MEDICALE" +* confidentiality = #N +* attester.mode = #legal +* attester.time = "2024-01-04T15:00:00+01:00" +* attester.party = Reference(urn:uuid:a11d31c5-77ff-4642-91f7-66c4d10d18c9) "DR Stéphane MEDIONI" +* custodian = Reference(urn:uuid:579f1274-8265-4bb1-91ba-d093a11be4f5) "Centre de soins le Belvédère" +* relatesTo.code = #replaces +* relatesTo.targetIdentifier.type = $v2-0203#RI "Relates to Identifier" +* relatesTo.targetIdentifier.system = "urn:ietf:rfc:3986" +* relatesTo.targetIdentifier.value = "urn:uuid:8D5E778C-E155-4685-95C6-5FF65A362964" +* event.extension.url = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-performer-event" +* event.extension.valueReference = Reference(urn:uuid:a11d31c5-77ff-4642-91f7-66c4d10d18c9) "DR Stéphane MEDIONI" +* event.period.start = "2024-04-21T08:00:00+01:00" +* section[0].title = "Problèmes actifs" +* section[=].code = $loinc#11450-4 "Liste des problèmes actifs" +* section[=].text.status = #generated +* section[=].text.div = "
DateTypeProblèmeSévéritéStatut du problèmeStatut clinique du patientCertitudeCommentaireDocument référencé
2023-07-05interprétation diagnostiqueThyroïdite auto-immunemodéréActifen formeConfirmé
2023-07-05interprétation diagnostiqueDiabète insulino-dépendantmodéréActifen formeConfirmé
2023-05-21interprétation diagnostiqueÉpilepsiemodéréActifen formeConfirmé
2023-05-21interprétation diagnostiqueAngiœdème bradykiniqueléger à modéréActifasymptomatiqueConfirmé
2023-05-21interprétation diagnostiqueCauses inconnues et non précisées de morbiditélégerRécurrenten formeNon confirmétexte libre
" +* section[=].entry[0] = Reference(urn:uuid:257427f5-dffa-4a97-9475-4ebb988589af) +* section[=].entry[+] = Reference(urn:uuid:4d6a4b74-b2a7-4ec1-8db1-8925f435a916) +* section[=].entry[+] = Reference(urn:uuid:af0e13e5-d0a2-4dbc-b892-7328eca72ff4) +* section[=].entry[+] = Reference(urn:uuid:a4d49149-cda7-470d-a2e3-08f8d7db1bad) +* section[=].entry[+] = Reference(urn:uuid:803caba9-c128-4faa-94a0-d344738ebc63) +* section[+].title = "Antécédents" +* section[=].code = $loinc#11348-0 "Antécédents médicaux" +* section[=].text.status = #generated +* section[=].text.div = "
DateTypeProblèmeSévéritéStatut du problèmeStatut clinique du patientCertitudeCommentaire
2018-05-21interprétation diagnostiqueAccident Ischémique Cérébral TransitoiremodéréRésoluen formeNon confirmétexte libre
2018-05-21interprétation diagnostiquePyélonéphrite aiguëmodéréRésoluen formeNon confirmétexte libre
" +* section[=].entry[0] = Reference(urn:uuid:effd6c8a-6122-46cb-82ed-ef3f300ec17b) +* section[=].entry[+] = Reference(urn:uuid:18492799-4e37-47a7-b79b-18a4d0597963) +* section[+].title = "Historique des actes" +* section[=].code = $loinc#47519-4 "Historique des actes" +* section[=].text.status = #generated +* section[=].text.div = "
DateActeVoie d'abordLocalisation anatomiqueMotifCommentaire
14/01/2018Dilatation intraluminale de 2 vaisseaux coronaires avec pose d'endoprothèse, par voie artérielle transcutanéeVoie intraartérielleartère coronaireInfarctus inférieur transmural(texte libre)
08/12/2016Autre acte (texte libre)---(texte libre)
" +* section[=].entry[0] = Reference(urn:uuid:4e00844f-241b-47c0-85a4-9d612c46b3ad) +* section[=].entry[+] = Reference(urn:uuid:3c6ec5d8-182d-4dfc-871b-59c9eb91aa51) +* section[+].title = "Allergies, hypersensibilités non allergiques, intolérances, idiosyncrasie" +* section[=].code = $loinc#48765-2 "Allergies et hypersensibilités" +* section[=].text.status = #generated +* section[=].text.div = "
DateTypeAgent responsableStatutCriticitéCertitudeRéaction(s)Sévérité réaction(s)Commentaire
04/12/2021Allergie médicamenteuseParacétamolActifBasConfirméBronchospasme d'origine médicamenteuse
Troubles allergiques ou d'hypersensibilité de la peau ou des muqueuses		modéré
léger		(texte libre)
" +* section[=].entry = Reference(urn:uuid:0ccf6c51-d3f5-4817-bc24-7f63a2ef3c7f) +* section[+].title = "Effets indésirables prévisibles liés aux médicaments" +* section[=].code = $loinc#44939-7 "Effets indésirables prévisibles liés aux médicaments" +* section[=].text.status = #generated +* section[=].text.div = "
DateTypeAgent responsableSubstance(s) incriminée(s)PosologieVoie d’administrationRéaction(s)ImputabilitéGravitéEvolutionCommentaire
04/12/2021interaction médicamenteuseAMOXICILLINE EG 1G BUV SACH 6AMOXICILLINE TRIHYDRATÉE1 g / 2 fois par jourvoie oralenauséesprobableNon graveGuérison sans séquelle(texte libre)
" +* section[=].entry = Reference(urn:uuid:23f1c0a3-ce38-4817-9408-7feaeb04002d) +* section[+].title = "Traitements" +* section[=].code = $loinc#10160-0 "Historique de la prise médicamenteuse" +* section[=].text.status = #generated +* section[=].text.div = "

Traitements au long cours :

Date de débutDate de finMédicamentFréquenceDose prescriteRythmeVoie d'administrationMotifCommentaire
11/01/2024–LEVOTHYROX 75 microgrammes, comprimé sécable1 fois/j1 cp–Voie oraleThyroïdite auto-immuneLe patient a pris le médicament après le petit-déjeuner
" +* section[=].entry = Reference(urn:uuid:1ff316e0-edde-4bb9-a5fe-822d486d8230) +* section[+].title = "Dispositifs médicaux" +* section[=].code = $loinc#46264-8 "Dispositifs médicaux" +* section[=].text.status = #generated +* section[=].text.div = "
Date débutDate finType de DMID du DMCommentaire
11/08/2019STIMULATEUR CARDIAQUE IMPLANTABLE TRIPLE CHAMBREinconnuStimulateur cardiaque contrôlé et fonctionnel
11/08/2013Autre DM : (texte libre)inconnu(texte libre)
" +* section[=].entry[0] = Reference(urn:uuid:034d19b3-3c4e-488a-a7c0-9181dfc721e3) +* section[=].entry[+] = Reference(urn:uuid:f38b1772-ca78-4578-be14-f7a493b2cbb9) +* section[+].title = "Points de vigilance" +* section[=].code = $loinc#44944-7 "Autres alertes" +* section[=].text.status = #generated +* section[=].text.div = "

Surveiller tension artérielle

" +* section[+].title = "Statut fonctionnel" +* section[=].code = $loinc#47420-5 "Évaluation du statut fonctionnel" +* section[=].text.status = #generated +* section[=].text.div = "
DateTypeObservationCommentaire
14/01/2018Score de performance ECOGCapable d’une activité identique à celle précédant la maladie sans aucune restriction (LOINC : LA9622-7)(texte libre)
14/01/2018MarcherRestriction modérée de la performance de marche sur de courtes distances (CIF : d4500.3)(texte libre)
" +* section[=].entry[0] = Reference(urn:uuid:960ebfbc-4b56-40b9-9990-cae5944d6e9b) +* section[=].entry[+] = Reference(urn:uuid:b9bca1ce-b850-408c-966c-26a1a87adf65) +* section[+].title = "Constantes" +* section[=].code = $loinc#8716-3 "Signes vitaux" +* section[=].text.status = #generated +* section[=].text.div = "
Signe vitalValeurDate de la mesureCommentaire
Poids58 kg02/04/2024(texte libre)
Taille1,60 m02/04/2024(texte libre)
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DateTypeObservationCommentaire
non renseignéeStatut tabagiqueFumeur quotidien(Texte libre)
non renseignéeConsommation tabagique25 PA(Texte libre)
non renseignéeConsommation d'alcool5 verres / jour(Texte libre)
non renseignéeConsommation de drogueCannabis(Texte libre)
" +* section[=].entry[0] = Reference(urn:uuid:48129cb5-0a81-4a17-aebd-8c6584b20cd4) +* section[=].entry[+] = Reference(urn:uuid:3618f351-cea4-4834-8cf9-10151b74436b) +* section[=].entry[+] = Reference(urn:uuid:4f0f3856-74a9-4a57-b173-e8342735d6c9) +* section[=].entry[+] = Reference(urn:uuid:3799b968-d637-4a16-ad7b-5f79987dcdb1) +* section[+].title = "Facteurs de risques professionnels" +* section[=].code = $loinc#10161-8 "Facteurs de risques professionnels" +* section[=].text.status = #generated +* section[=].text.div = "

Contact répété avec solvants organiques (atelier peinture)

" +* section[+].title = "Facteurs de risques professionnels" +* section[=].code = $loinc#10157-6 "Historique des pathologies familiales" +* section[=].text.status = #generated +* section[=].text.div = "
Lien de parentéAntécédentCommentaire
MèreAnémie à hématies falciformes sans crises (CIM-10 : D57.1)(texte libre)
" +* section[=].entry = Reference(urn:uuid:541404fa-fc9c-4552-8d36-10adcc37f34e) +* section[+].title = "Vaccinations" +* section[=].code = $loinc#11369-6 "Historique des vaccinations" +* section[=].text.status = #generated +* section[=].text.div = "
DateMaladie(s) prévenue(s)VaccinLot n°Type / RangVoieRégion d'administrationRéaction observéeVaccinateurCommentaire
28/09/2009Diphtérie-poliomyélite-tétanosREVAXIS, suspension injectable en seringue préremplie. Vaccin diphtérique, tétanique et poliomyélitique (inactivé), adsorbé, à teneur réduite en antigènes44566721ère série vaccinante / 2Voie intramusculaireDeltoïde gaucheFièvre due à des médicamentsDr Charles MULLERPrise récente et ponctuelle de solupred (60mg) en une prise pendant 2 jours
25/08/2009Diphtérie-poliomyélite-tétanosREVAXIS, suspension injectable en seringue préremplie. Vaccin diphtérique, tétanique et poliomyélitique (inactivé), adsorbé, à teneur réduite en antigènes44566681ère série vaccinante / 1Voie intramusculaireDeltoïde gaucheFièvre due à des médicamentsDr Charles MULLER-
" +* section[=].entry[0] = Reference(urn:uuid:7f0d585b-9a48-4605-baab-30e93603a563) +* section[=].entry[+] = Reference(urn:uuid:3a7417c1-d483-4f56-833d-43bf8e438874) +* section[+].title = "Historique des grossesses" +* section[=].code = $loinc#10162-6 "Historique des grossesses" +* section[=].text.status = #generated +* section[=].text.div = "
ObservationPrécision
Statut de grossessepatiente actuellement enceinte
Date prévisionnelle d'accouchement03/09/2024
Nb d'enfants vivants1
Nombre d'interruptions de grossesse1
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Traitements médicamenteux :

MédicamentCommentaire
ROSUVASTATINE EG 5 mg, comprimé pelliculé(texte libre)
Autre traitement : (texte libre)(texte libre)

Demandes d'examens ou de suivis :

Date envisagéeDemandeCommentaire
01/12/2024Cholestérol LDL(Texte libre)
01/12/2024Autre examen (texte libre)(Texte libre)

Actes :

Date envisagéePrioritéActeCommentaire
01/12/2024Bénéfique pour le patient mais pas essentiel pour sa surviePose d'une prothèse auditive implantable dans l'oreille moyenne(Texte libre)
01/12/2024Aussi vite que possibleAutre acte (texte libre)(Texte libre)

Rencontres :

Date envisagéeType de rencontrePersonneLieuCommentaire
01/12/2024AmbulatoirePR Jacques PETITJEAN (Médecin - Oncologie, opt Onco-hématologie (SM))Hôpital Lariboisière (Service hématologie)(Texte libre)

Vaccins recommandés :

Période de vaccination souhaitableVaccinCommentaire
entre le 01/12/2024 et le 31/12/2024Vaccin antituberculeux(Texte libre)
entre le 01/12/2024 et le 31/12/2024Autre vaccin (texte libre)(Texte libre)
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"Paracétamol" +* reaction[=].manifestation = $terminologie-cim11-mms#4A80.0 "Bronchospasme d'origine médicamenteuse" +* reaction[=].onset = "2021-12-04" +* reaction[=].severity = #moderate +* reaction[+].substance = $terminologie-cim11-mms#XM5DJ7 "Paracétamol" +* reaction[=].manifestation = $terminologie-cim11-mms#4A82 "Troubles allergiques ou d'hypersensibilité de la peau ou des muqueuses" +* reaction[=].onset = "2021-12-04" +* reaction[=].severity = #mild +* reaction[=].note.text = "texte libre" + +Instance: EffetIndesirable-Exemple-1 +InstanceOf: AdverseEvent +Usage: #inline +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-effet-indesirable" +* identifier.system = "urn:oid:1.2.3.999" +* identifier.value = "C64C6013-C8AF-4938-AD10-1B7D26DEE2A0" +* actuality = #actual +* category = $sct#79899007 "interaction médicamenteuse" +* subject = Reference(urn:uuid:00f54e2e-22f2-4162-87b4-4826d855feac) +* date = "2021-12-04" +* detected = "2021-12-04" +* resultingCondition = Reference(urn:uuid:a4e1cafa-05e4-40c7-82dc-641f54281671) +* seriousness = $sct#255604002 "gravité légère" +* outcome = $sct#1352007006 "Guérison sans séquelle" +* suspectEntity.instance = Reference(urn:uuid:0409af90-4717-4a93-9800-fcf546875dc8) +* suspectEntity.causality.assessment = $sct#17162000 "certain(e)" + +Instance: MedicationAdministration-Exemple-1 +InstanceOf: MedicationAdministration +Usage: #inline +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-medication-administration-document" +* extension.url = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-administration-frequency" +* extension.valueTiming.repeat.frequency = 1 +* extension.valueTiming.repeat.period = 12 +* extension.valueTiming.repeat.periodUnit = #h +* identifier.system = "urn:oid:1.2.3.999" +* identifier.value = "55915ED6-0682-4588-9F4A-FB71210F7015" +* status = #completed +* category = $v3-ActCode#DRUG "Médicament" +* 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dosage.rateQuantity.extension.url = "http://hl7.org/fhir/StructureDefinition/data-absent-reason" +* dosage.rateQuantity.extension.valueCode = #not-applicable + +Instance: Medication-Exemple-2 +InstanceOf: Medication +Usage: #inline +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-medication-document" +* extension[0].url = "https://profiles.ihe.net/PHARM/MPD/StructureDefinition/ihe-ext-medication-productname" +* extension[=].valueString = "LEVOTHYROX 75 microgrammes" +* extension[+].url = "https://profiles.ihe.net/PHARM/MPD/StructureDefinition/ihe-ext-medication-classification" +* extension[=].valueCodeableConcept = $terminologie-atc#H03AA01 "lévothyroxine sodique" +* extension[=].valueCodeableConcept.text = "lévothyroxine sodique" +* code = $terminologie-bdpm#3400930065785 "LEVOTHYROX 75 microgrammes, comprimé sécable plaquette(s) PVC aluminium de 30 comprimé(s)" +* ingredient.itemCodeableConcept.extension.url = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-nom-substance" +* ingredient.itemCodeableConcept.extension.valueString = "paracetamol" +* ingredient.itemCodeableConcept = $terminologie-sms#100000091647 "LÉVOTHYROXINE SODIQUE" +* ingredient.strength.numerator.value = 75 +* ingredient.strength.numerator.unit = "mg" +* ingredient.strength.denominator.value = 1 + +Instance: DeviceUseStatement-Exemple-1 +InstanceOf: DeviceUseStatement +Usage: #inline +* meta.profile = "https://interop.esante.gouv.fr/ig/document/core/StructureDefinition/fr-device-use-statement-medicaldevice" +* identifier.extension.url = "http://hl7.org/fhir/StructureDefinition/data-absent-reason" +* identifier.extension.valueCode = #unknown +* status = #active +* subject = Reference(urn:uuid:00f54e2e-22f2-4162-87b4-4826d855feac) +* timingPeriod.start = "2019-08-11" +* device = Reference(urn:uuid:7bb3e1f4-15bd-4c06-a587-3445c0f5a530) "STIMULATEUR CARDIAQUE IMPLANTABLE TRIPLE CHAMBRE" +* note.text = 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