Australian Digital Health Agency FHIR Implementation Guide

A transfer summary includes critical information for exchange of information between providers of care when a patient moves between health care settings.

TBD

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42349-1 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

TBD

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42348-3 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about allergies or intolerances identified or reported during this encounter. This may include statements that a patient does not have an allergy or category of allergies.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 48765-2 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA), and C-CDA on FHIR.

The use of concept 101.20113 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information on the patient's medicine item use on admission. Admission may be to a long-term facility, hopsital, or home health.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42346-7 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

A description of a patient's medicine history at a point in time. The list may be partial, or complete, and may be a history or scoped to may be taking the medication now or has taken the medication in the past or will be taking the medication in the future.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 10160-0 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of concept 101.16146 or 101.16022 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Vital signs associated with a patient.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 8716-3 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about the immunisation history, i.e. administered vaccines, of a patient.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11369-6 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of concept 101.16638 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about the clinical problems or conditions currently being monitored for a patient.

The inclusion of a problems section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11450-4 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about the history of past illness for a patient including the history related to their current complaints, problems, or diagnoses.

The inclusion of a past medical history section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR, and National guidelines for on-screen presentation of discharge summaries' published by the Australian Commission on Safety and Quality in Health Care in August 2016.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11348-0 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about the clinical problems or conditions currently being monitored for a patient.

The inclusion of a problems section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR, and National guidelines for on-screen presentation of discharge summaries' published by the Australian Commission on Safety and Quality in Health Care in August 2016.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 47519-4 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Information about the medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 46264-8 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

A transfer summary includes critical information for exchange of information between providers of care when a patient moves between health care settings.

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

The workflow/clinical status of the composition.

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Type of a composition.

Key metadata element describing the composition, used in searching/filtering.

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

This is a metadata field from XDS/MHD.

High-level kind of a clinical document at a macro level.

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

This is a metadata field from XDS/MHD.

High-level kind of a clinical document at a macro level.

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

For clinical documents, this is usually the patient.

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Describes the clinical encounter or type of care this documentation is associated with.

Provides context for the composition and supports searching.

The composition editing time, when the composition was last logically changed by the author.

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Identifies who is responsible for the content.

Official human-readable label for the composition.

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

The code specifying the level of confidentiality of the Composition.

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Codes specifying the level of confidentiality of the composition.

The root of the sections that make up the composition.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

If a section is empty, why it is empty.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

TBD

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42349-1 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

TBD

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42348-3 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about allergies or intolerances identified or reported during this encounter. This may include statements that a patient does not have an allergy or category of allergies.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 48765-2 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA), and C-CDA on FHIR.

The use of concept 101.20113 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information on the patient's medicine item use on admission. Admission may be to a long-term facility, hopsital, or home health.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 42346-7 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

A description of a patient's medicine history at a point in time. The list may be partial, or complete, and may be a history or scoped to may be taking the medication now or has taken the medication in the past or will be taking the medication in the future.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 10160-0 adopted for this section is aligned with the vocabulary in Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of concept 101.16146 or 101.16022 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Vital signs associated with a patient.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 8716-3 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about the immunisation history, i.e. administered vaccines, of a patient.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11369-6 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of concept 101.16638 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may also be supplied as an additional coding or it may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about the clinical problems or conditions currently being monitored for a patient.

The inclusion of a problems section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11450-4 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about the history of past illness for a patient including the history related to their current complaints, problems, or diagnoses.

The inclusion of a past medical history section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR, and National guidelines for on-screen presentation of discharge summaries' published by the Australian Commission on Safety and Quality in Health Care in August 2016.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 11348-0 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about the clinical problems or conditions currently being monitored for a patient.

The inclusion of a problems section adopted is in line with the section grouping in the International Patient Summary (IPS), Consolidated CDA (C-CDA), C-CDA on FHIR, and National guidelines for on-screen presentation of discharge summaries' published by the Australian Commission on Safety and Quality in Health Care in August 2016.

The use of a single grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 47519-4 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

The use of a grouping Medical History section with concept 101.16117 from the Agency's NCTIS (National Clinical Terminology and Information Service) Data Components code system is deprecated but may be present in older data.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Information about the medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

The code identifies the section for an automated processor of the document. When sharing health records it is important that globally adopted vocabulary is supported to allow for ubiquitous discovery, access, and re-use. To meet this need, where a consistent vocabulary and common syntax to achieve semantic interoperability is widely adopted internationally that code is adopted in Agency materials.

The LOINC concept 46264-8 adopted for this section is aligned with the vocabulary in International Patient Summary (IPS), Consolidated CDA (C-CDA) and C-CDA on FHIR.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Classification of a section of a composition/document.

Provides computable standardized labels to topics within the document.

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

A transfer summary includes critical information for exchange of information between providers of care when a patient moves between health care settings.

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.