HL7 FHIR Costa Rica - Reportes de Imágenes Médicas
0.0.1-draft - ci-build

HL7 FHIR Costa Rica - Reportes de Imágenes Médicas, published by Iniciativa HL7 Costa Rica. This guide is not an authorized publication; it is the continuous build for version 0.0.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cr/imaging-report/ and changes regularly. See the Directory of published versions

## Resource Profile: CR Composition - Imaging Report

Official URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-composition-imaging-report | Version:
Standards status: Draft | Maturity Level: 0 | Computable Name: CRCompositionImagingReport
Copyright/Legal: Utilizado con permiso de HL7 International, todos los derechos reservados Licencia Creative Commons

Composición para el documento de reporte de imágenes médicas en Costa Rica. Contiene el texto narrativo estructurado del reporte.

Usages:

- Examples for this Profile: Composition/composition-xray-example

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 72134-0
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
subject | S Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Human Readable name/title
section | S C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
text | S C | 1..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 | C | 0..* | Reference(ImagingStudy | Observation) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.status | Base | required | Composition Status | 📍5.0.0 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std.
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
cmp-1 | error | Composition.section | 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 | 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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 | Composition.implicitRules, Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.identifier, Composition.status, Composition.type, Composition.subject, Composition.date, Composition.author, Composition.title, Composition.section, Composition.section.modifierExtension, Composition.section.title, Composition.section.code, Composition.section.text, Composition.section.entry | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.section.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Composition

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history
identifier |  | 0..1 | Identifier | Version-independent identifier for the Composition
status | S | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
type |  | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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: 72134-0
subject | S | 1..1 | Reference(Patient) | Who and/or what the composition is about
date | S | 1..1 | dateTime | Composition editing time
author | S | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
title | S | 1..1 | string | Human Readable name/title
section | S | 1..* | BackboneElement | Composition is broken into sections
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation
entry |  | 0..* | Reference(ImagingStudy | Observation) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
text |  | 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 Constraints: ext-1
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique)
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 72134-0
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
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ReferencedItemCategoryValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition
date | S Σ | 1..1 | dateTime | Composition editing time
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support
author | S Σ | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
name | Σ | 0..1 | string | Name for this Composition (computer friendly)
title | S Σ | 1..1 | string | Human Readable name/title
note |  | 0..* | Annotation | For any additional notes
attester |  | 0..* | BackboneElement | Attests to accuracy of composition
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
mode |  | 1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition
relatesTo |  | 0..* | RelatedArtifact | Relationships to other compositions/documents
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
section | S C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
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 | S C | 1..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
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(ImagingStudy | Observation) | 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 |  | 0..* | See section (Composition) | Nested Section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
Composition.status | Base | required | Composition Status | 📍5.0.0 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std.
Composition.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std.
Composition.attester.​mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std.
Composition.event.detail | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v7.1
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
Composition.section.​orderedBy | Base | preferred | List Order Codes | 📍5.0.0 | FHIR Std.
Composition.section.​emptyReason | Base | preferred | List Empty Reasons | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
cmp-1 | error | Composition.section | 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 | 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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 | Composition.meta, Composition.implicitRules, Composition.language, Composition.text, Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.url, Composition.identifier, Composition.version, Composition.status, Composition.type, Composition.category, Composition.subject, Composition.encounter, Composition.date, Composition.useContext, Composition.author, Composition.name, Composition.title, Composition.note, Composition.attester, Composition.attester.extension, Composition.attester.modifierExtension, Composition.attester.mode, Composition.attester.time, Composition.attester.party, Composition.custodian, Composition.relatesTo, Composition.event, Composition.event.extension, Composition.event.modifierExtension, Composition.event.period, Composition.event.detail, Composition.section, Composition.section.extension, Composition.section.modifierExtension, Composition.section.title, Composition.section.code, Composition.section.author, Composition.section.focus, Composition.section.text, Composition.section.orderedBy, Composition.section.entry, Composition.section.emptyReason, Composition.section.section | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.attester.extension, Composition.attester.modifierExtension, Composition.event.extension, Composition.event.modifierExtension, Composition.section.extension, Composition.section.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Composition

Summary

Mandatory: 5 elements
Must-Support: 12 elements

Structures

This structure refers to these other structures:

- Patient (http://hl7.org/fhir/StructureDefinition/Patient|5.0.0)
- Practitioner (http://hl7.org/fhir/StructureDefinition/Practitioner|5.0.0)
- Device (http://hl7.org/fhir/StructureDefinition/Device|5.0.0)
- ImagingStudy (http://hl7.org/fhir/StructureDefinition/ImagingStudy|5.0.0)
- Observation (http://hl7.org/fhir/StructureDefinition/Observation|5.0.0)

Extensions

This structure refers to these extensions:

- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history

Maturity: 0

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 72134-0
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
subject | S Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
title | S Σ | 1..1 | string | Human Readable name/title
section | S C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
text | S C | 1..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 | C | 0..* | Reference(ImagingStudy | Observation) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.status | Base | required | Composition Status | 📍5.0.0 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std.
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
cmp-1 | error | Composition.section | 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 | 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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 | Composition.implicitRules, Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.identifier, Composition.status, Composition.type, Composition.subject, Composition.date, Composition.author, Composition.title, Composition.section, Composition.section.modifierExtension, Composition.section.title, Composition.section.code, Composition.section.text, Composition.section.entry | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.section.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from Composition

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history
identifier |  | 0..1 | Identifier | Version-independent identifier for the Composition
status | S | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
type |  | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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: 72134-0
subject | S | 1..1 | Reference(Patient) | Who and/or what the composition is about
date | S | 1..1 | dateTime | Composition editing time
author | S | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
title | S | 1..1 | string | Human Readable name/title
section | S | 1..* | BackboneElement | Composition is broken into sections
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation
entry |  | 0..* | Reference(ImagingStudy | Observation) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition |  | 0..* | Composition(5.0.0) | A set of resources composed into a single coherent clinical statement with clinical attestation
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
text |  | 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 Constraints: ext-1
extension:impression | S | 0..* | Reference(Observation | Condition) | Impresión radiológica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation | S | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones derivadas del estudio URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory | S | 0..* | Reference(Observation) | Historial relevante del paciente URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique)
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 72134-0
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
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ReferencedItemCategoryValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition
date | S Σ | 1..1 | dateTime | Composition editing time
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support
author | S Σ | 1..* | Reference(Practitioner | Device) | Who and/or what authored the composition
name | Σ | 0..1 | string | Name for this Composition (computer friendly)
title | S Σ | 1..1 | string | Human Readable name/title
note |  | 0..* | Annotation | For any additional notes
attester |  | 0..* | BackboneElement | Attests to accuracy of composition
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
mode |  | 1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition
relatesTo |  | 0..* | RelatedArtifact | Relationships to other compositions/documents
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
period | Σ | 0..1 | Period | The period covered by the documentation
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
section | S C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible)
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 | S C | 1..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
orderedBy |  | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry | C | 0..* | Reference(ImagingStudy | Observation) | 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 |  | 0..* | See section (Composition) | Nested Section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
Composition.status | Base | required | Composition Status | 📍5.0.0 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std.
Composition.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std.
Composition.attester.​mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std.
Composition.event.detail | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v7.1
Composition.section.​code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
Composition.section.​orderedBy | Base | preferred | List Order Codes | 📍5.0.0 | FHIR Std.
Composition.section.​emptyReason | Base | preferred | List Empty Reasons | 📍5.0.0 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
cmp-1 | error | Composition.section | 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 | 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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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 | Composition.meta, Composition.implicitRules, Composition.language, Composition.text, Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.url, Composition.identifier, Composition.version, Composition.status, Composition.type, Composition.category, Composition.subject, Composition.encounter, Composition.date, Composition.useContext, Composition.author, Composition.name, Composition.title, Composition.note, Composition.attester, Composition.attester.extension, Composition.attester.modifierExtension, Composition.attester.mode, Composition.attester.time, Composition.attester.party, Composition.custodian, Composition.relatesTo, Composition.event, Composition.event.extension, Composition.event.modifierExtension, Composition.event.period, Composition.event.detail, Composition.section, Composition.section.extension, Composition.section.modifierExtension, Composition.section.title, Composition.section.code, Composition.section.author, Composition.section.focus, Composition.section.text, Composition.section.orderedBy, Composition.section.entry, Composition.section.emptyReason, Composition.section.section | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | Composition.extension, Composition.extension:impression, Composition.extension:recommendation, Composition.extension:patientHistory, Composition.modifierExtension, Composition.attester.extension, Composition.attester.modifierExtension, Composition.event.extension, Composition.event.modifierExtension, Composition.section.extension, Composition.section.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Composition

Summary

Mandatory: 5 elements
Must-Support: 12 elements

Structures

This structure refers to these other structures:

- Patient (http://hl7.org/fhir/StructureDefinition/Patient|5.0.0)
- Practitioner (http://hl7.org/fhir/StructureDefinition/Practitioner|5.0.0)
- Device (http://hl7.org/fhir/StructureDefinition/Device|5.0.0)
- ImagingStudy (http://hl7.org/fhir/StructureDefinition/ImagingStudy|5.0.0)
- Observation (http://hl7.org/fhir/StructureDefinition/Observation|5.0.0)

Extensions

This structure refers to these extensions:

- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history

Maturity: 0

Other representations of profile: CSV, Excel, Schematron