PCC - mobile Paramedicine Summary of Care (mPSC)
2.0.0-draft - ci-build
PCC - mobile Paramedicine Summary of Care (mPSC)
2.0.0-draft - ci-build
PCC - mobile Paramedicine Summary of Care (mPSC), published by IHE Patient Care Coordination. This guide is not an authorized publication; it is the continuous build for version 2.0.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/PCC.PCS/ and changes regularly. See the Directory of published versions
| Official URL: https://profiles.ihe.net/PCC/mPSC/StructureDefinition/IHE.PCC.FHIR.MS.Composition | Version: 2.0.0-draft | |||
| Draft as of 2025-10-30 | Computable Name: IHE_PCC_FHIR_MedicalSummary_Composition | |||
A FHIR representation of IHE's Medical Summary Document…. Utilizing IPS as a template
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
  Composition |
C | 0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation Constraints: clindoc-limit-participantType | ||||||||
  meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
   profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
 Slices for extension |
Content/Rules for all slices | |||||||||||
  extension:R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||||||
| extension:data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||||||
| extension:informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||||||
| extension:information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||||||
| extension:participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||||||
| extension:consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||||||
| extension:basedOn |
S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | ||||||||
 extension:change-made |
S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
 Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status | ||||||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||||||
| type |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:text Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||||||
| category:clinicalnotecategory |
SΣ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 107903-7 | |||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Clinical note | |||||||||
| 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(IHE PCC Patient) | Who and/or what the composition is about | ||||||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | ||||||||
 attester:All Slices |
Content/Rules for all slices | |||||||||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target | ||||||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Closed by type:$this | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: replaces | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document | |||||||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||||||
| use |
?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| Slices for event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | ||||||||
| event:All Slices |
Content/Rules for all slices | |||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
SΣ | 0..1 | Period | The period covered by the documentation | ||||||||
| Slices for section |
SC | 3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:problem |
SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:allergyOrIntolerance |
SC | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:medicationStatementOrRequest |
SC | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionPayers |
SC | 0..1 | BackboneElement | IHE Payers Section Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| entry |
SC | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📦4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:legal_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:professional_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.event:careProvisioningEvent.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.section.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. |
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
|
| cmp-1 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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()
|
| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
|
This structure is derived from ClinicalDocumentComposition
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||||||
| meta |
||||||||||||
| profile |
S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error | ||||||||
| type |
1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) | |||||||||
| subject |
1..1 | Reference(IHE PCC Patient) | Who and/or what the composition is about | |||||||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| Slices for attester |
Content/Rules for all slices | |||||||||||
| attester:legal_attester |
0..1 | BackboneElement | aka legal authenticator | |||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
0..* | BackboneElement | aka authenticator | |||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||||||
 target[x] |
1..1 | Target of the relationship | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| Slices for event |
0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |||||||||
| event:careProvisioningEvent |
S | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented | ||||||||
| period |
S | 0..1 | Period | The period covered by the documentation | ||||||||
| Slices for section |
3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code | |||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| section |
0..0 | Nested Section | ||||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: ihe-pcc-comp-1 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:problem |
S | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:allergyOrIntolerance |
S | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:medicationStatementOrRequest |
S | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionPayers |
0..1 | BackboneElement | IHE Payers Section | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| entry |
S | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. Slice: Unordered, Open by profile:resolve() | ||||||||
| Documentation for this format | ||||||||||||
| Id | Grade | Path(s) | Description | Expression |
| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
|
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation Constraints: clindoc-limit-participantType | ||||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
 extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||||||
| extension:data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||||||
| extension:informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||||||
| extension:information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||||||
| extension:participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||||||
| extension:consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||||||
| extension:basedOn |
S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | ||||||||
| extension:change-made |
S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status | ||||||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||||||
| type |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:text Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||||||
| category:clinicalnotecategory |
SΣ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 107903-7 | |||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Clinical note | |||||||||
| 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(IHE PCC Patient) | Who and/or what the composition is about | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | ||||||||
| attester:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target | ||||||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Closed by type:$this | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: replaces | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| use |
?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||||||
| system |
Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||||||
| Slices for event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | ||||||||
| event:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
SΣ | 0..1 | Period | The period covered by the documentation | ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| Slices for section |
SC | 3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:problem |
SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:allergyOrIntolerance |
SC | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:medicationStatementOrRequest |
SC | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionPayers |
SC | 0..1 | BackboneElement | IHE Payers Section Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| entry |
SC | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. | ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| Composition.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| Composition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📦4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:legal_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:professional_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.event:careProvisioningEvent.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.section.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. |
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
|
| cmp-1 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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()
|
| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
|
This structure is derived from ClinicalDocumentComposition
Summary
Mandatory: 7 elements(2 nested mandatory elements)
Must-Support: 22 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation Constraints: clindoc-limit-participantType | ||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||||||
| extension:data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||||||
| extension:informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||||||
| extension:information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||||||
| extension:participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||||||
| extension:consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||||||
| extension:basedOn |
S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | ||||||||
| extension:change-made |
S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status | ||||||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||||||
| type |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:text Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||||||
| category:clinicalnotecategory |
SΣ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 107903-7 | |||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Clinical note | |||||||||
| 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(IHE PCC Patient) | Who and/or what the composition is about | ||||||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | ||||||||
| attester:All Slices |
Content/Rules for all slices | |||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target | ||||||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Closed by type:$this | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: replaces | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document | |||||||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||||||
| use |
?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| Slices for event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | ||||||||
| event:All Slices |
Content/Rules for all slices | |||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
SΣ | 0..1 | Period | The period covered by the documentation | ||||||||
| Slices for section |
SC | 3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:problem |
SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:allergyOrIntolerance |
SC | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| Slices for entry |
C | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:medicationStatementOrRequest |
SC | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionPayers |
SC | 0..1 | BackboneElement | IHE Payers Section Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| entry |
SC | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📦4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:legal_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:professional_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.event:careProvisioningEvent.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.section.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. |
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
|
| cmp-1 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | 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()
|
| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
|
Differential View
This structure is derived from ClinicalDocumentComposition
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||||||
| meta |
||||||||||||
| profile |
S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error | ||||||||
| type |
1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) | |||||||||
| subject |
1..1 | Reference(IHE PCC Patient) | Who and/or what the composition is about | |||||||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| Slices for attester |
Content/Rules for all slices | |||||||||||
| attester:legal_attester |
0..1 | BackboneElement | aka legal authenticator | |||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
0..* | BackboneElement | aka authenticator | |||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||||||
| target[x] |
1..1 | Target of the relationship | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| Slices for event |
0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |||||||||
| event:careProvisioningEvent |
S | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented | ||||||||
| period |
S | 0..1 | Period | The period covered by the documentation | ||||||||
| Slices for section |
3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code | |||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| section |
0..0 | Nested Section | ||||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: ihe-pcc-comp-1 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:problem |
S | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:allergyOrIntolerance |
S | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: ihe-pcc-comp-1
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| Slices for entry |
0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | |||||||||
| entry:medicationStatementOrRequest |
S | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty | ||||||||
| section:sectionPayers |
0..1 | BackboneElement | IHE Payers Section | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:change-made |
0..1 | ChangeMade | Change Made | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| entry |
S | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. Slice: Unordered, Open by profile:resolve() | ||||||||
| Documentation for this format | ||||||||||||
| Id | Grade | Path(s) | Description | Expression |
| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
|
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | ClinicalDocumentComposition | A set of resources composed into a single coherent clinical statement with clinical attestation Constraints: clindoc-limit-participantType | ||||||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||||||
| extension:data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||||||
| extension:informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||||||
| extension:information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||||||
| extension:participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||||||
| extension:consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||||||
| extension:basedOn |
S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | ||||||||
| extension:change-made |
S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status | ||||||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||||||
| type |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:text Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||||||
| category:clinicalnotecategory |
SΣ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 107903-7 | |||||||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Clinical note | |||||||||
| 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(IHE PCC Patient) | Who and/or what the composition is about | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | ||||||||
| attester:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional | ||||||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||||||
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target | ||||||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Closed by type:$this | ||||||||||
| targetIdentifier |
Identifier | |||||||||||
| targetReference |
Reference(Composition | Composition (IPS) | FHIR Clinical Document Composition Profile) | |||||||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: replaces | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends | |||||||||
| Slices for target[x] |
1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this | |||||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
| use |
?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||||||
| system |
Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||||||
| value |
Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||||||
| Slices for event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | ||||||||
| event:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The care provisioning being documented | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| code |
SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||||||
| period |
SΣ | 0..1 | Period | The period covered by the documentation | ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| Slices for section |
SC | 3..* | BackboneElement | Sections composing a Medical Summary Document Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2 | ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionProblems |
SC | 1..1 | BackboneElement | Problems Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:problem |
SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionAllergies |
SOC | 1..1 | BackboneElement | Allergies and Intolerances Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances for that patient. Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:allergyOrIntolerance |
SC | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionMedications |
SOC | 1..1 | BackboneElement | Medication Summary Section Constraints: cmp-1, cmp-2, ihe-pcc-comp-1
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| Slices for entry |
C | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||||||
| entry:medicationStatementOrRequest |
SC | 0..* | Reference(MedicationStatement (IPS) | MedicationRequest (IPS)) | A reference to data that supports this section | ||||||||
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section:sectionPayers |
SC | 0..1 | BackboneElement | IHE Payers Section Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:change-made |
S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade | ||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||||||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) 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 | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||||||
| entry |
SC | 0..* | Reference(Observation | DocumentReference | Coverage | Contract | InsurancePlan) | information about the patient's sources of payment. | ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| Composition.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| Composition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📦4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| Composition.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:legal_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.attester:professional_attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:replaced_document.target[x]:targetIdentifier.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo:appended_document.target[x]:targetIdentifier.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.event:careProvisioningEvent.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v6.5 |
| Composition.section.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionMedications.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.code | Base | example | Document Section Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.orderedBy | Base | preferred | List Order Codes | 📦4.0.1 | FHIR Std. |
| Composition.section:sectionPayers.emptyReason | Base | preferred | List Empty Reasons | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. |
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and
extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
|
| cmp-1 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | A section must contain at least one of text, entries, or sub-sections |
text.exists() or entry.exists() or section.exists()
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| cmp-2 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionPayers | A section can only have an emptyReason if it is empty |
emptyReason.empty() or entry.empty()
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| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
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| 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()
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| 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()
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| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
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| dom-6 | best practice | Composition | A resource should have narrative for robust management |
text.`div`.exists()
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| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
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| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
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| ihe-pcc-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present |
(entry.reference.exists() or emptyReason.exists())
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This structure is derived from ClinicalDocumentComposition
Summary
Mandatory: 7 elements(2 nested mandatory elements)
Must-Support: 22 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ IHE Patient Care Coordination. Package ihe.pcc.mpsc#2.0.0-draft based on FHIR 4.0.1. Generated 2025-10-30
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