Generated Narrative: StructureDefinition cz-composition-amb Name Flags Card. Type Description & Constraints <a href="StructureDefinition-cz-composition-amb-definitions.html#Composition" title="Outpatient Encounter Report Composition. #xD;#xA;#xD;#xA; A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. #xD;#xA;While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.">Composition 0..* Composition Outpatient Encounter Report Composition #xD; meta #xD; security S 0..* Coding Security Labels applied to this resource #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:basedOn 0..* (Complex) Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn #xD; value[x] 1..1 Reference(Resource | ServiceRequest) Value of extension #xD; extension:presentedForm 1..* (Complex) Presented form URL: https://hl7.cz/fhir/core/StructureDefinition/presentedForm #xD; value[x] #xD; contentType 0..1 code Mime type of the content, with charset etc. Example pdf: application/pdf #xD; data 0..1 base64Binary B64 in-line data #xD; url 0..1 url URL of the document #xD; identifier 0..1 Identifier Report identifier #xD; status 1..1 code Status of the Order #xD; subject 1..1 Reference(Patient (CZ core)) Who and/or what the composition is about #xD; encounter 0..1 Reference(Encounter (CZ)) Context that defines the Outpatient Encounter Report #xD; date 1..1 dateTime Date the order was created. #xD; author 1..* Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ)) Who and/or what authored the Outpatient Encounter Report #xD; custodian 0..1 Reference(Organization (CZ core)) Organization that manages the Outpatient Encounter Report #xD; Slices for section 0..* BackboneElement Composition is broken into sections Slice: Unordered, Open by pattern:code #xD; section:sectionAdvanceDirectives 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 42348-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Advance directives #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Consent (Advance Directives) (HDR CZ) | Consent | DocumentReference) A reference to data that supports this section #xD; section:sectionAllergies 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 48765-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Allergies and intolerances #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(AllergyIntolerance: Outpatient Encounter Report (CZ) | Allergy Intolerance (CZ) | AllergyIntolerance | DocumentReference) A reference to data that supports this section #xD; section:sectionAlerts 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 104605-1 #xD; display 1..1 string Representation defined by the system Fixed Value: Alerts #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Flag: Outpatient Encounter Report (CZ) | Flag | DocumentReference) A reference to data that supports this section #xD; section:sectionClinicalStatusAtPresentation 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 51848-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Evaluation note #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:sectionPatientHistory 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 35090-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Patient history #xD; Slices for section 0..* Nested Section Slice: Unordered, Open by pattern:code #xD; section:PastIllnessHx 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Past illness history #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11348-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Past illness history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Condition | DocumentReference) A reference to data that supports this section #xD; section:HistoryMedicalDevices 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: History of medical devices #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 46264-8 #xD; display 1..1 string Representation defined by the system Fixed Value: History of medical device use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Device | DeviceUseStatement | DocumentReference) A reference to data that supports this section #xD; section:ProceduresHx 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Procedures history #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11369-6 #xD; display 1..1 string Representation defined by the system Fixed Value: Procedures history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Procedure | DocumentReference) A reference to data that supports this section #xD; section:Immunizations 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Immunizations #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11369-6 #xD; display 1..1 string Representation defined by the system Fixed Value: Immunizations history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Immunization | DocumentReference) A reference to data that supports this section #xD; section:InfectiousContacts 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Infectious contacts #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11348-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Infectious disease contact #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:TravelHx 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Travel history #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11347-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Travel history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:FamilyHistory 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Family history #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10157-6 #xD; display 1..1 string Representation defined by the system Fixed Value: Family history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(FamilyMemberHistory | DocumentReference) A reference to data that supports this section #xD; section:SocialHistory 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Sociální anamnéza #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29762-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Social history #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:AlcoholUse 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Alcohol use #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 72163-9 #xD; display 1..1 string Representation defined by the system Fixed Value: Alcohol use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:TobaccoUse 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Tobacco use #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 72164-7 #xD; display 1..1 string Representation defined by the system Fixed Value: Tobacco use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:DrugUse 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Drug use #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 72165-4 #xD; display 1..1 string Representation defined by the system Fixed Value: Drug use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:OtherAddictions 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Other addictions #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 72166-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Other addictions #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DocumentReference) A reference to data that supports this section #xD; section:sectionEncounterSummary 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 67781-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Summarization of encounter note #xD; Slices for section 0..* Nested Section Slice: Unordered, Open by pattern:code #xD; section:ProblemList 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Diagnostický souhrn #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11450-4 #xD; display 1..1 string Representation defined by the system Fixed Value: Problem list #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Condition | ClinicalImpression) A reference to data that supports this section #xD; section:ProceduresAndTreatments 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Výkony #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29554-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Procedure Narrative #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Procedure | MedicationAdministration) A reference to data that supports this section #xD; section:MedicalDevices 0..1 BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Zdravotní pomůcky a implantáty #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 46264-8 #xD; display 1..1 string Representation defined by the system Fixed Value: History of medical device use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Device | DeviceUseStatement) A reference to data that supports this section #xD; section:MedicationDuring 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Medikace během ambulantního kontaktu #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29549-3 #xD; display 1..1 string Representation defined by the system Fixed Value: Medication administered Narrative #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(MedicationAdministration | MedicationStatement) A reference to data that supports this section #xD; section:Results 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Výsledky vyšetření #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 30954-2 #xD; display 1..1 string Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data note #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(Observation | DiagnosticReport | ImagingStudy) A reference to data that supports this section #xD; section:ClinicalSummary 0..* BackboneElement Nested Section #xD; title 0..1 string Label for section (e.g. for ToC) Required Pattern: Klinické shrnutí #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 51848-0 #xD; display 1..1 string Representation defined by the system Fixed Value: Evaluation note #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(ClinicalImpression) A reference to data that supports this section #xD; section:sectionMedicationSummary 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10160-0 #xD; display 1..1 string Representation defined by the system Fixed Value: History of medication use #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(MedicationStatement | MedicationRequest | DocumentReference) A reference to data that supports this section #xD; section:sectionPlanOfCare 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 18776-5 #xD; display 1..1 string Representation defined by the system Fixed Value: Plan of care #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(CarePlan | DocumentReference) A reference to data that supports this section #xD; section:sectionAttachments 0..1 BackboneElement Composition is broken into sections #xD; title 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 77599-9 #xD; display 1..1 string Representation defined by the system Fixed Value: Additional documentation #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; entry 0..* Reference(DocumentReference) A reference to data that supports this section #xD; Documentation for this format
Composition: Outpatient Encounter Report (CZ)
Clinical document used to represent an Outpatient Encounter Report for the scope of this guide.
Outpatient Encounter Report composition is an electronic health record extract containing Outpatient Encounter Report.
Outpatient Encounter Report Composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.
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.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. 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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
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.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be 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. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
A plan, proposal or order that is fulfilled in whole or in part by this event.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Source of the definition for the extension code - a logical name or a URL.
The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R4/extensibility.html) for a list).
Human readable representation of the entire document. Multiple formats are allowed but they SHALL be semantically equivalent.
Mime type of the content, with charset etc.
Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.
Processors of the data need to be able to know how to interpret the data.
The mime type of an attachment. Any valid mime type is allowed.
ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
The human language of the content. The value can be any valid value according to BCP 47.
Users need to be able to choose between the languages in a set of attachments.
The actual data of the attachment - a sequence of bytes, base64 encoded.
The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.
The data needs to able to be transmitted inline.
A location where the data can be accessed.
If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.
The data needs to be transmitted by reference.
RP.1+RP.2 - if they refer to a URL (see v2.6)
Number of bytes of content (if url provided)
The number of bytes of data that make up this attachment (before base64 encoding, if that is done).
The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.
Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.
The calculated hash of the data using SHA-1. Represented using base64.
The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R4/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.
Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).
A label or set of text to display in place of the data.
Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.
The date that the attachment was first created.
This is often tracked as an integrity issue for use of the attachment.
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).
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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Identifiers assigned to this report by the performer or other systems. It shall be common to several report versions
Composition.identifier SHALL be equal to one of the OrderInformation.identifier, if at least one exists
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.
Need to be able to mark interim, amended, or withdrawn compositions or documents.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
The workflow/clinical status of the composition.
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
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.
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](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).
Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
Who and/or what the composition is about
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.
Context that defines the Outpatient Encounter Report
Describes the clinical encounter or type of care this documentation is associated with.
Provides context for the composition and supports searching.
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
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](http://hl7.org/fhir/R4/bundle-definitions.html#Bundle.timestamp) is the date of packaging.
DocumentReference.content.attachment.date, DocumentReference.created
Who and/or what authored the Outpatient Encounter Report
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.
DocumentReference.description, DocumentReference.content.attachment.title
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.
A participant who has attested to the accuracy of the composition/document.
Identifies responsibility for the accuracy of the composition content.
Extensions that cannot be ignored even if unrecognized
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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
personal | professional | legal | official
The type of attestation the authenticator offers.
Indicates the level of authority of the attestation.
The way in which a person authenticated a composition.
implied by .authenticator/.legalAuthenticator
When the composition was attested by the party.
Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
./time[type="TS" and isNormalDatatype()]
Who attested the composition in the specified way.
Identifies who has taken on the responsibility for accuracy of the composition content.
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
Organization that manages the Outpatient Encounter Report
Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Identifies where to go to find the current version, where to report issues, etc.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Relationships to other compositions/documents
Relationships that this composition has with other compositions or documents that already exist.
A document is a version specific composition.
The type of relationship that this composition has with anther composition or document.
If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
The type of relationship between documents.
The target composition/document of this relationship.
.target[classCode="DOC", moodCode="EVN"].id
The clinical service(s) being documented
The clinical service, such as a colonoscopy or an appendectomy, being documented.
The event needs to be consistent with the type element, though can provide further information if desired.
Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Code(s) that apply to the event being documented
This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
This list of codes represents the main clinical acts being documented.
The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
The root of the sections that make up the composition.
A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
exists(f:text) or exists(f:entry) or exists(f:section)
A section can only have an emptyReason if it is empty
not(exists(f:emptyReason) and exists(f:entry))
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
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.
Provides computable standardized labels to topics within the document.
Classification of a section of a composition/document.
Identifies who is responsible for the information in this section, not necessarily who typed it in.
Who/what the section is about, when it is not about the subject of composition
The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
.subject? (CDA did not differentiate between subject and focus)
Text summary of the section, for human interpretation
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.
How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
The processing mode that applies to this section.
Specifies the order applied to the items in the section entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
What order applies to the items in the entry.
.outboundRelationship[typeCode=COMP].sequenceNumber > 1
A reference to data that supports this section
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.
.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
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 nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
Relevant diagnostic tests/laboratory data note