Introduction

This profile is used to represent the clinical content present within a health care survey report.

Sections and Population Criteria

The following sections and population criteria should be used to create the composition resource below.

To support reduction in Bundle sizes and limit duplicate data, in most cases data should be limited to the current encounter.

• Patient: The patient who is the subject of the encounter
• Encounter: The encounter that was closed (updated documentation to be added to the encounter before stating it is closed)
• Conditions/Problems/HealthConcerns:
  • Encounter diagnosis for the closed encounter
  • All statuses except inactive; verificationStatus = confirmed
• MedicationRequests: Medication requested during the encounter with status = active and completed; intent = order.
• MedicationAdministration: Medication administered during the encounter with status = active.
• Medications: Medications referenced by MedicationRequests and MedicationAdministration.
• Vital Signs: Vital signs for the encounter with status = final or status = amended.
• Allergies: Allergies associated with the patient with status = active; verificationStatus = confirmed.
• Procedures: All interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized.
• ServiceRequest: Procedures ordered during the encounter.
• Immunizations: Immunizations associated with the patient.
• LabResults: Results linked to the encounter, ordered during the encounter, received during the encounter, or received within a specified timeframe (e.g., 48 - 72 hours) after the encounter closes with status = final or status = preliminary.
• Lab Reporting: Results linked to the encounter, ordered during the encounter, received during the encounter, or received within a specified timeframe (e.g., 48 - 72 hours) after the encounter closes with status = final or status = preliminary.
• Diagnostic Report Notes:
  • Results linked to the encounter, ordered during the encounter, received during the encounter, or received within a specified timeframe (e.g., 48 - 72 hours) after the encounter closes with status = final or status = preliminary.
  • Procedure Notes.
  • Imaging data is NOT to be sent.
• Clinical Notes: All notes created during the encounter.
• Care Team: Associated with the patient with status = active.
• CarePlan: Associated with the encounter with status = draft or status = active.
• Goals: status = proposed or status = planned or status = accepted or status = active.
• Smoking Status: Associated with the patient.
• Implantable Devices: Associated with the patient.
• Pregnancy Status: Associated with the patient.

The above data to be populated by the implementers of the DataSource actor.

USCDI Mappings

USCDI V3.1 mappings are noted in the Descriptions & Constraints section of the profile below. For comprehensive mappings see US Core USCDI Guidance (note that US Core 6.1.0 was published prior to USCDI V3.1 so the mappings are to USCDI V3.0).

The following two profiles are not specifically constrained in the Composition but can be used or are referenced as stated below:

• US Core RelatedPerson Profile (USCDI Data Class: Patient Demographics | USCDI Data Elements: Related Person's Name, Related Person's Relationship) is referenced from the following US Core Profiles:
  • US Core CareTeam Profile, US Core Coverage Profile, US Core DocumentReference Profile, US Core Encounter Profile, US Core MedicationDispense Profile, US Core MedicationRequest Profile, US Core Observation Screening Assessment Profile, US Core Provenance Profile, US Core QuestionnaireResponse Profile, US Core ServiceRequest Profile and US Core Simple Observation Profile
• US Core Provenance Profile (USCDI Data Class: Provenance | USCDI Data Elements: Author Time Stamp, Author Organization) is supported for the following US Core resources:
  • AllergyIntolerance, CarePlan, CareTeam, Condition, Coverage, Device, DiagnosticReport, DocumentReference, Encounter, Goal, Immunization, MedicationDispense, MedicationRequest, Observation, Patient, Procedure, QuestionnaireResponse, RelatedPerson, ServiceRequest

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	Health Care Surveys Composition
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..1	Identifier	Health Care Surveys Composition identifier
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. Fixed Value: final
type	SΣ	1..1	CodeableConcept	National Health Care Surveys report Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 75619-7
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(US Core Patient Profile(6.1.0))	Patient who is the subject of the report.
encounter	SΣ	1..1	Reference(US Core Encounter Profile(6.1.0))	Encounter related to the public health event
date	SΣ	1..1	dateTime	Composition editing time
author	SΣ	1..*	Reference(US Core PractitionerRole Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core Organization Profile(6.1.0) | Device)	The author(s) of the document
title	SΣ	1..1	string	Human Readable name/title Fixed Value: National Health Care Surveys report
Slices for section	SC	3..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
section:reasonForVisitSection	SC	1..1	BackboneElement	Reason for Visit Section Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Reason for Visit code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29299-5
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Reason for Visit narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:problemSection	SC	1..1	BackboneElement	Problem Section (USCDI Data Class: Problems, Encounter) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Problem Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11450-4
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Problem Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:problemsHealthConcerns	SC	0..*	Reference(US Core Condition Problems and Health Concerns Profile(6.1.0))	Problems Health Concerns Entries (USCDI Data Elements: Date of Resolution, Date of Diagnosis, SDOH Problems/Health Concerns, Health Concerns, Disability Status, Functional Status, Mental/Cognitive Status)
entry:encounterDiagnosis	SC	0..*	Reference(US Core Condition Encounter Diagnosis Profile(6.1.0))	Encounter Diagnosis Entries (USCDI Data Elements: Encounter Diagnosis)
section:allergiesSection	SC	1..1	BackboneElement	Allergies Section (USCDI Data Class: Allergies and Intolerances) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Allergies Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 48765-2
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Allergies Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core AllergyIntolerance Profile(6.1.0))	AllergyIntolerance Entries (USCDI Data Elements: Substance (Medication), Substance (Drug Class), Reaction)
section:assessmentAndPlanOfTreatmentSection	SC	0..1	BackboneElement	Assessment Section (USCDI Data Class: Assessment and Plan of Treatment, Health Status/Assessments) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Assessment and Plan of Treatment Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 51847-2
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Evaluation + Plan note This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:screeningAssessment	SC	0..*	Reference(US Core Observation Screening Assessment Profile | US Core Simple Observation Profile)	Assessment Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)
entry:questionnaireResponse	SC	0..*	Reference(US Core QuestionnaireResponse Profile(6.1.0))	QuestionnaireResponse Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)
entry:carePlan	SC	0..*	Reference(US Core CarePlan Profile(6.1.0))	CarePlan Entries (USCDI Data Elements: Assessment and Plan of Treatment)
section:careTeamSection	SC	0..1	BackboneElement	Care Team Section (USCDI Data Class: Care Team Members) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Care Team Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 85847-2
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Care Team Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core CareTeam Profile(6.1.0))	Care Team Entries (USCDI Data Elements: Care Team Members - Name, Identifier, Location, Telecom, Role)
section:coverageSection	SC	0..1	BackboneElement	Coverage Section (USCDI Data Class: Health Insurance Information) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Coverage Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 48768-6
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Coverage Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core Coverage Profile)	Coverage Entries (USCDI Data Elements: Coverage Status, Coverage Type, Relationship to Subscriber, Member Identifier, Subscriber Identifier, Group Number, Payer Identifier)
section:goalsSection	SC	0..1	BackboneElement	Goals Section (USCDI Data Class: Goals) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Goals Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 61146-7
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Goals Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core Goal Profile(6.1.0))	Goal Entries (USCDI Data Elements: Patient Goals, SDOH Goals)
section:immunizationsSection	SC	0..1	BackboneElement	Immunizations Section (USCDI Data Class: Immunization) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Immunizations code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11369-6
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Immunizations narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core Immunization Profile(6.1.0))	Immunization Entries (USCDI Data Elements: Immunizations)
section:medicalEquipmentSection	SC	0..1	BackboneElement	Medical Equipment Section (USCDI Data Class: Unique Device Identifier(s) for a patient's implantable device(s)) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Medical Equipment Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 46264-8
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Medical Equipment Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(US Core Implantable Device Profile(6.1.0))	Implantable Device Entries (USCDI Data Elements: Unique Device Identifier(s) for a patient's implantable device(s))
section:medicationsSection	SC	0..1	BackboneElement	Medications Section (USCDI Data Class: Medications) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Medications Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 10160-0
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Medications Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:medicationAdministration	SC	0..*	Reference(Health Care Surveys Medication Administration)	MedicationAdministration Entries (USCDI Data Elements: Medications, Dose)
entry:medicationRequest	SC	0..*	Reference(US Core MedicationRequest Profile(6.1.0))	MedicationRequest Entries (USCDI Data Elements: Medications, Dose, Dose Unit of Measure, Indication)
entry:medicationDispense	SC	0..*	Reference(US Core MedicationDispense Profile)	MedicationDispense Entries (USCDI Data Elements: Medications, Fill Status)
entry:medication	SC	0..*	Reference(US Core Medication Profile(6.1.0))	Medication Entries (USCDI Data Elements: Medications)
section:clinicalNotesSection	SC	0..*	BackboneElement	Clinical Notes Section Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Clinical Notes Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 28650-0
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Clinical Notes Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:documentReference	SC	0..*	Reference(US Core DocumentReference Profile(6.1.0))	Document Reference Entries (USCDI Data Elements: Consultation Note, Discharge Summary Note, History & Physical, Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note, Progress Note)
entry:diagnosticReport	SC	0..*	Reference(US Core DiagnosticReport Profile for Report and Note Exchange(6.1.0))	Diagnostic Report Entries (USCDI Data Elements: Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note)
section:pregnancySection	SC	0..1	BackboneElement	Pregnancy Section (USCDI Data Class: Health Status/Assessments - Pregnancy Status) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Pregnancy Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 90767-5
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Pregnancy Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:pregnancyStatusObservation	SC	0..*	Reference(US Core Observation Pregnancy Status Profile)	Pregnancy Status Entries (USCDI Data Elements: Pregnancy Status)
entry:pregnancyIntent	SC	0..*	Reference(US Core Observation Pregnancy Intent Profile)	Pregnancy Intent Entries (USCDI Data Elements: Pregnancy Status)
section:proceduresSection	SC	0..1	BackboneElement	Procedures Section (USCDI Data Class: Procedures) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Procedures Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 47519-4
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Procedures Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:procedure	SC	0..*	Reference(US Core Procedure Profile(6.1.0))	Procedure Entries (USCDI Data Elements: Procedure, SDOH Interventions)
entry:procedureOrder	SC	0..*	Reference(US Core ServiceRequest Profile(6.1.0))	Procedure Order Entries (USCDI Data Elements: Reason for Referral, SDOH Interventions)
section:resultsSection	SC	0..1	BackboneElement	Results Section (USCDI Data Class: Laboratory, Clinical Tests) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Results Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 30954-2
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Results Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:result	SC	0..*	Reference(US Core Laboratory Result Observation Profile(6.1.0) | US Core Observation Clinical Result Profile)	Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)
entry:diagnosticReport	SC	0..*	Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting(6.1.0) | US Core DiagnosticReport Profile for Report and Note Exchange(6.1.0))	Diagnostic Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)
section:socialHistorySection	SC	0..1	BackboneElement	Social History Section (USCDI Data Class: Health Status/Assessments - Smoking Status, Patient Demographics/Information - Occupation, Occupation Industry) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Social History Section code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 29762-2
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Social History Section narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:smokingStatus	SC	0..*	Reference(US Core Smoking Status Observation Profile(6.1.0))	Smoking Status Entries (USCDI Data Elements: Smoking Status)
entry:occupation	SC	0..*	Reference(US Core Observation Occupation Profile)	Occupation Entries (USCDI Data Elements: Occupation, Occupation Industry)
section:vitalSignsSection	SC	0..*	BackboneElement	Vital Signs Section (USCDI Data Class: Vital Signs) Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Vital Signs code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 8716-3
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	SC	1..1	Narrative	Vital Signs narrative This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry	SC	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:bloodPressure	SC	0..*	Reference(US Core Blood Pressure Profile(6.1.0))	Blood Pressure Entries (USCDI Data Elements: Systolic Blood Pressure, Diastolic Blood Pressure)
entry:bodyWeight	SC	0..*	Reference(US Core Body Weight Profile(6.1.0))	Body Weight Entries (USCDI Data Elements: Body Weight)
entry:bodyHeight	SC	0..*	Reference(US Core Body Height Profile(6.1.0))	Body Height Entries (USCDI Data Elements: Body Height)
entry:heartRate	SC	0..*	Reference(US Core Heart Rate Profile(6.1.0))	Heart Rate Entries (USCDI Data Elements: Heart Rate)
entry:pulseOximetry	SC	0..*	Reference(US Core Pulse Oximetry Profile(6.1.0))	Pulse Oximetry Entries (USCDI Data Elements: Pulse Oximetry)
entry:pediatricWeightForHeight	SC	0..*	Reference(US Core Pediatric Weight for Height Observation Profile(6.1.0))	Pediatric Weight For Height Entries (USCDI Data Elements: Pediatric Weight For Length Percentile (Birth to 36 months))
entry:pediatricHeadOccipitalFrontalCircumference	SC	0..*	Reference(US Core Pediatric Head Occipital Frontal Circumference Percentile Profile(6.1.0))	Pediatric Head Occipital Frontal Circumference Percentile Entries (USCDI Data Elements: Occipital Frontal Head Circumference Percentile (Birth to 36 months))
entry:pediatricBMIForAge	SC	0..*	Reference(US Core Pediatric BMI for Age Observation Profile(6.1.0))	Pediatric BMI For Age Entries (USCDI Data Elements: BMI Percentile (2-20 years old))
entry:bodyTemperature	SC	0..*	Reference(US Core Body Temperature Profile(6.1.0))	Body Temperature Entries (USCDI Data Elements: Body Temperature)
entry:respiratoryRate	SC	0..*	Reference(US Core Respiratory Rate Profile(6.1.0))	Respiratory Rate Entries (USCDI Data Elements: Respiratory Rate)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.section:reasonForVisitSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:problemSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:allergiesSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:assessmentAndPlanOfTreatmentSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:careTeamSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:coverageSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:goalsSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:immunizationsSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medicalEquipmentSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:medicationsSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:clinicalNotesSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:pregnancySection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:proceduresSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:resultsSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:socialHistorySection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:vitalSignsSection.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cmp-1	error	Composition.section, Composition.section:reasonForVisitSection, Composition.section:problemSection, Composition.section:allergiesSection, Composition.section:assessmentAndPlanOfTreatmentSection, Composition.section:careTeamSection, Composition.section:coverageSection, Composition.section:goalsSection, Composition.section:immunizationsSection, Composition.section:medicalEquipmentSection, Composition.section:medicationsSection, Composition.section:clinicalNotesSection, Composition.section:pregnancySection, Composition.section:proceduresSection, Composition.section:resultsSection, Composition.section:socialHistorySection, Composition.section:vitalSignsSection	A section must contain at least one of text, entries, or sub-sections	text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:reasonForVisitSection, Composition.section:problemSection, Composition.section:allergiesSection, Composition.section:assessmentAndPlanOfTreatmentSection, Composition.section:careTeamSection, Composition.section:coverageSection, Composition.section:goalsSection, Composition.section:immunizationsSection, Composition.section:medicalEquipmentSection, Composition.section:medicationsSection, Composition.section:clinicalNotesSection, Composition.section:pregnancySection, Composition.section:proceduresSection, Composition.section:resultsSection, Composition.section:socialHistorySection, Composition.section:vitalSignsSection	A section can only have an emptyReason if it is empty	emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	Health Care Surveys Composition
identifier	S	1..1	Identifier	Health Care Surveys Composition identifier
status	S	1..1	code	preliminary | final | amended | entered-in-error Fixed Value: final
type	S	1..1	CodeableConcept	National Health Care Surveys report 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: 75619-7
subject	S	1..1	Reference(US Core Patient Profile(6.1.0))	Patient who is the subject of the report.
encounter	S	1..1	Reference(US Core Encounter Profile(6.1.0))	Encounter related to the public health event
date	S	1..1	dateTime	Composition editing time
author	S	1..*	Reference(US Core PractitionerRole Profile(6.1.0) | US Core Practitioner Profile(6.1.0) | US Core Organization Profile(6.1.0) | Device)	The author(s) of the document
title	S	1..1	string	Human Readable name/title Fixed Value: National Health Care Surveys report
Slices for section	S	3..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code
section:reasonForVisitSection	S	1..1	BackboneElement	Reason for Visit Section
code	S	1..1	CodeableConcept	Reason for Visit code 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: 29299-5
text	S	1..1	Narrative	Reason for Visit narrative
section:problemSection	S	1..1	BackboneElement	Problem Section (USCDI Data Class: Problems, Encounter)
code	S	1..1	CodeableConcept	Problem Section code 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
text	S	1..1	Narrative	Problem Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:problemsHealthConcerns	S	0..*	Reference(US Core Condition Problems and Health Concerns Profile(6.1.0))	Problems Health Concerns Entries (USCDI Data Elements: Date of Resolution, Date of Diagnosis, SDOH Problems/Health Concerns, Health Concerns, Disability Status, Functional Status, Mental/Cognitive Status)
entry:encounterDiagnosis	S	0..*	Reference(US Core Condition Encounter Diagnosis Profile(6.1.0))	Encounter Diagnosis Entries (USCDI Data Elements: Encounter Diagnosis)
section:allergiesSection	S	1..1	BackboneElement	Allergies Section (USCDI Data Class: Allergies and Intolerances)
code	S	1..1	CodeableConcept	Allergies Section code 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
text	S	1..1	Narrative	Allergies Section narrative
entry	S	0..*	Reference(US Core AllergyIntolerance Profile(6.1.0))	AllergyIntolerance Entries (USCDI Data Elements: Substance (Medication), Substance (Drug Class), Reaction)
section:assessmentAndPlanOfTreatmentSection	S	0..1	BackboneElement	Assessment Section (USCDI Data Class: Assessment and Plan of Treatment, Health Status/Assessments)
code	S	1..1	CodeableConcept	Assessment and Plan of Treatment Section code 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: 51847-2
text	S	1..1	Narrative	Evaluation + Plan note
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:screeningAssessment	S	0..*	Reference(US Core Observation Screening Assessment Profile | US Core Simple Observation Profile)	Assessment Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)
entry:questionnaireResponse	S	0..*	Reference(US Core QuestionnaireResponse Profile(6.1.0))	QuestionnaireResponse Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)
entry:carePlan	S	0..*	Reference(US Core CarePlan Profile(6.1.0))	CarePlan Entries (USCDI Data Elements: Assessment and Plan of Treatment)
section:careTeamSection	S	0..1	BackboneElement	Care Team Section (USCDI Data Class: Care Team Members)
code	S	1..1	CodeableConcept	Care Team Section code 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: 85847-2
text	S	1..1	Narrative	Care Team Section narrative
entry	S	0..*	Reference(US Core CareTeam Profile(6.1.0))	Care Team Entries (USCDI Data Elements: Care Team Members - Name, Identifier, Location, Telecom, Role)
section:coverageSection	S	0..1	BackboneElement	Coverage Section (USCDI Data Class: Health Insurance Information)
code	S	1..1	CodeableConcept	Coverage Section code 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: 48768-6
text	S	1..1	Narrative	Coverage Section narrative
entry	S	0..*	Reference(US Core Coverage Profile)	Coverage Entries (USCDI Data Elements: Coverage Status, Coverage Type, Relationship to Subscriber, Member Identifier, Subscriber Identifier, Group Number, Payer Identifier)
section:goalsSection	S	0..1	BackboneElement	Goals Section (USCDI Data Class: Goals)
code	S	1..1	CodeableConcept	Goals Section code 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: 61146-7
text	S	1..1	Narrative	Goals Section narrative
entry	S	0..*	Reference(US Core Goal Profile(6.1.0))	Goal Entries (USCDI Data Elements: Patient Goals, SDOH Goals)
section:immunizationsSection	S	0..1	BackboneElement	Immunizations Section (USCDI Data Class: Immunization)
code	S	1..1	CodeableConcept	Immunizations code 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
text	S	1..1	Narrative	Immunizations narrative
entry	S	0..*	Reference(US Core Immunization Profile(6.1.0))	Immunization Entries (USCDI Data Elements: Immunizations)
section:medicalEquipmentSection	S	0..1	BackboneElement	Medical Equipment Section (USCDI Data Class: Unique Device Identifier(s) for a patient's implantable device(s))
code	S	1..1	CodeableConcept	Medical Equipment Section code 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
text	S	1..1	Narrative	Medical Equipment Section narrative
entry	S	0..*	Reference(US Core Implantable Device Profile(6.1.0))	Implantable Device Entries (USCDI Data Elements: Unique Device Identifier(s) for a patient's implantable device(s))
section:medicationsSection	S	0..1	BackboneElement	Medications Section (USCDI Data Class: Medications)
code	S	1..1	CodeableConcept	Medications Section code 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
text	S	1..1	Narrative	Medications Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:medicationAdministration	S	0..*	Reference(Health Care Surveys Medication Administration)	MedicationAdministration Entries (USCDI Data Elements: Medications, Dose)
entry:medicationRequest	S	0..*	Reference(US Core MedicationRequest Profile(6.1.0))	MedicationRequest Entries (USCDI Data Elements: Medications, Dose, Dose Unit of Measure, Indication)
entry:medicationDispense	S	0..*	Reference(US Core MedicationDispense Profile)	MedicationDispense Entries (USCDI Data Elements: Medications, Fill Status)
entry:medication	S	0..*	Reference(US Core Medication Profile(6.1.0))	Medication Entries (USCDI Data Elements: Medications)
section:clinicalNotesSection	S	0..*	BackboneElement	Clinical Notes Section
code	S	1..1	CodeableConcept	Clinical Notes Section code 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: 28650-0
text	S	1..1	Narrative	Clinical Notes Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:documentReference	S	0..*	Reference(US Core DocumentReference Profile(6.1.0))	Document Reference Entries (USCDI Data Elements: Consultation Note, Discharge Summary Note, History & Physical, Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note, Progress Note)
entry:diagnosticReport	S	0..*	Reference(US Core DiagnosticReport Profile for Report and Note Exchange(6.1.0))	Diagnostic Report Entries (USCDI Data Elements: Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note)
section:pregnancySection	S	0..1	BackboneElement	Pregnancy Section (USCDI Data Class: Health Status/Assessments - Pregnancy Status)
code	S	1..1	CodeableConcept	Pregnancy Section code 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: 90767-5
text	S	1..1	Narrative	Pregnancy Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:pregnancyStatusObservation	S	0..*	Reference(US Core Observation Pregnancy Status Profile)	Pregnancy Status Entries (USCDI Data Elements: Pregnancy Status)
entry:pregnancyIntent	S	0..*	Reference(US Core Observation Pregnancy Intent Profile)	Pregnancy Intent Entries (USCDI Data Elements: Pregnancy Status)
section:proceduresSection	S	0..1	BackboneElement	Procedures Section (USCDI Data Class: Procedures)
code	S	1..1	CodeableConcept	Procedures Section code 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
text	S	1..1	Narrative	Procedures Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:procedure	S	0..*	Reference(US Core Procedure Profile(6.1.0))	Procedure Entries (USCDI Data Elements: Procedure, SDOH Interventions)
entry:procedureOrder	S	0..*	Reference(US Core ServiceRequest Profile(6.1.0))	Procedure Order Entries (USCDI Data Elements: Reason for Referral, SDOH Interventions)
section:resultsSection	S	0..1	BackboneElement	Results Section (USCDI Data Class: Laboratory, Clinical Tests)
code	S	1..1	CodeableConcept	Results Section code 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
text	S	1..1	Narrative	Results Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:result	S	0..*	Reference(US Core Laboratory Result Observation Profile(6.1.0) | US Core Observation Clinical Result Profile)	Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)
entry:diagnosticReport	S	0..*	Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting(6.1.0) | US Core DiagnosticReport Profile for Report and Note Exchange(6.1.0))	Diagnostic Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)
section:socialHistorySection	S	0..1	BackboneElement	Social History Section (USCDI Data Class: Health Status/Assessments - Smoking Status, Patient Demographics/Information - Occupation, Occupation Industry)
code	S	1..1	CodeableConcept	Social History Section code 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
text	S	1..1	Narrative	Social History Section narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:smokingStatus	S	0..*	Reference(US Core Smoking Status Observation Profile(6.1.0))	Smoking Status Entries (USCDI Data Elements: Smoking Status)
entry:occupation	S	0..*	Reference(US Core Observation Occupation Profile)	Occupation Entries (USCDI Data Elements: Occupation, Occupation Industry)
section:vitalSignsSection	S	0..*	BackboneElement	Vital Signs Section (USCDI Data Class: Vital Signs)
code	S	1..1	CodeableConcept	Vital Signs code 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
text	S	1..1	Narrative	Vital Signs narrative
Slices for entry	S	0..*	Reference(Resource)	A reference to data that supports this section Slice: Unordered, Open by profile:resolve()
entry:bloodPressure	S	0..*	Reference(US Core Blood Pressure Profile(6.1.0))	Blood Pressure Entries (USCDI Data Elements: Systolic Blood Pressure, Diastolic Blood Pressure)
entry:bodyWeight	S	0..*	Reference(US Core Body Weight Profile(6.1.0))	Body Weight Entries (USCDI Data Elements: Body Weight)
entry:bodyHeight	S	0..*	Reference(US Core Body Height Profile(6.1.0))	Body Height Entries (USCDI Data Elements: Body Height)
entry:heartRate	S	0..*	Reference(US Core Heart Rate Profile(6.1.0))	Heart Rate Entries (USCDI Data Elements: Heart Rate)
entry:pulseOximetry	S	0..*	Reference(US Core Pulse Oximetry Profile(6.1.0))	Pulse Oximetry Entries (USCDI Data Elements: Pulse Oximetry)
entry:pediatricWeightForHeight	S	0..*	Reference(US Core Pediatric Weight for Height Observation Profile(6.1.0))	Pediatric Weight For Height Entries (USCDI Data Elements: Pediatric Weight For Length Percentile (Birth to 36 months))
entry:pediatricHeadOccipitalFrontalCircumference	S	0..*	Reference(US Core Pediatric Head Occipital Frontal Circumference Percentile Profile(6.1.0))	Pediatric Head Occipital Frontal Circumference Percentile Entries (USCDI Data Elements: Occipital Frontal Head Circumference Percentile (Birth to 36 months))
entry:pediatricBMIForAge	S	0..*	Reference(US Core Pediatric BMI for Age Observation Profile(6.1.0))	Pediatric BMI For Age Entries (USCDI Data Elements: BMI Percentile (2-20 years old))
entry:bodyTemperature	S	0..*	Reference(US Core Body Temperature Profile(6.1.0))	Body Temperature Entries (USCDI Data Elements: Body Temperature)
entry:respiratoryRate	S	0..*	Reference(US Core Respiratory Rate Profile(6.1.0))	Respiratory Rate Entries (USCDI Data Elements: Respiratory Rate)
Documentation for this format