Content (cs)

Popis základních částí obrazové zprávy

Informace o žádance (objednávce)

Zobrazovací metody jsou prováděny na vyžádání (obvykle) indikujícím lékařem. Žádanka by měla obsahovat také zdůvodnění vyšetření. Žádanky (objednávky) chodí v listinné podobě nebo elektronicky. Vždy jsou zaevidované v informačním systému (RIS/HIS/AIS). Ze žádanek se pak tvoří jednotlivé pracovní požadavky pro modality (přístroje). Údaje ze žádanek se obvykle přebírají do ZPRÁV automatizovaně.

Důvod vyžádání (indikace)

Důvod vyžádání zdravotní služby. Zpráva může reagovat na více uvedených důvodů. Důvod vyžádání by měl být obsažen v žádance (objednávce).

Informace o vzorku

Informace o vzorku, pokud je předmětem vyšetření vzorek materiálu. Biologický druh se týká vzorků odebraných jiným než lidským subjektům. Materiál odebraného vzorku, čas odběru, anatomické umístění, morfologické abnormality anatomického umístění, odkud je materiál odebrán, například „rána“ nebo „vřed“ apod. Pro většinu údajů je navržen kódový systém SNOMED CT.

Výkon (procedura)

Typ výkonu
Klasifikace vyšetření. V současnosti se využívá klasifikace ERTN, ke které ÚZIS udržuje mapování na kódy výkonů číselníku VZP. Navrženo je i používání LOINC „Imaging Document Codes“ nebo zajistit také mapování české radiologické klasifikace (ČRK) na LOINC.

Část těla
Popis části těla, případně lateralita („stranovost“), na které je prováděn výkon. Strukturovaně nebo minimálně volným textem.

Modalita
Zobrazovací modalita (zkratka), která provedla obrazový záznam. DICOM Standards PS 3.3-2011, Section C.7.3.1.1.1

Důvod provedení
Důvod provedení výkonu, uvedený zdravotnickým pracovníkem odpovědným za provedení výkonu. Může být jiný, než který byl uveden v žádance indikujícím lékařem, nebo jej doplňuje.

Technika provedení výkonu
Popis technického provedení zobrazovací metody (např. použité MR sekvence, projekce snímku atd.). Obsahuje navíc kódované položky. Popis technického provedení lze provézt i formalizovaným zápisem, tj. strukturovaně, ale minimálně (povinně) volným textem. Popis technického provedení obsahuje také informace o podání látky, např. kontrastní látky nebo jiného léčivého přípravku podaného v souvislosti s výkonem (např. kontrastní látka nebo lék na uklidnění apod.). Povinně musí být uveden min. název léčivého přípravku, dávka a datum a čas podání. Vznikne-li po podání nežádoucí reakce, musí se zaznamenat také informace o nežádoucí reakci.

Výsledky
Popis výsledků provedených výkonů (vyšetření) musí být minimálně volným textem a kód typu pozorování (SNOMED CT).

Závěr
Závěr shrnuje nejdůležitější nálezy a/nebo diagnózy, které byly učiněny na základě výsledků zobrazovací metody (případně s přihlédnutím k jiným klinickým informacím). Tento oddíl může obsahovat volným textem popis klinického závěru a/nebo kódované hodnocení, například kategorie BI-RADS nebo ekvivalentní.

Doporučení
Doporučení může obsahovat např. doporučení následných vyšetření nebo postupů, které vyplynuly z výsledků a/nebo závěrů. Strukturovaná část této položky je shodná se stejnojmennou položkou v propouštěcí zprávě.

Předchozí výkony

Odkaz na související předchozí provedené zobrazovací metody, např. pro porovnání výsledků nebo trendů, nebo na starší verzi Zprávy změněnou touto Zprávou. Příslušná Zpráva musí patřit stejnému pacientovi. Návrh nepředepisuje způsob implementace, jakým uživatelským způsobem budou informace o předchozích vyšetřeních připojována. Možná je i poznámka volným textem.

Média (jiné přílohy)

Klíčové snímky související s touto Zprávou. Může být více příloh. Kromě metadat popisujících jednotlivá připojená média může být přílohou skutečný obsah média (inline) nebo přímý odkaz na zdrojový soubor média. Kromě metadat může být k příloze zadán volný text. Návrh nepředepisuje způsob implementace, jakým uživatelským způsobem budou média připojována. Součástí médií, tedy příloh, může být také výstupy z přístrojů ve formě obrázků (např. křivky EKG, snímky z mikroskopu apod.) a také důvěryhodná forma dokumentu („otisk“ dokumentu PDF/A s kvalifikovaným podpisem).

DICOM metadata

Vybrané relevantní údaje z DICOM studie bez obrazových dat. Cílem je, aby údaje byly dostupné pro všechny uživatele bez nutnosti přenosu celých DICOM obrazových studií a bez nutnosti software umožňujícího čtení z DICOM dat z obrazových studií. Údaje, které jsou součástí DICOM dat se nepřepisují, ale připojí se ke Zprávě (do Zprávy) automaticky. „Konzument“ Zprávy dostane informace o obrazové studii a může získat jen náhledy na některé série, některé snímky a to „proklikem“ ze zprávy apod.

Content (en)

Imaging Report structure

Information about the request (order)

Imaging methods are performed upon request (usually) by the referring physician. The request should also contain the justification for the examination. Requests (orders) are sent in paper form or electronically. They are always registered in the information system (RIS/HIS/AIS). Individual work requirements for modalities (devices) are then created from the request. Data from the request is usually automatically transferred to the REPORTS.

Reason for request (indication)

Reason for requesting health services. The report can respond to more than one of the reasons listed. The reason for the request should have been included in the request (order).

Sample information

Information about the sample, if the material is the subject of testing. Biological species refers to samples taken from subjects other than human subjects. Material of the sample taken, time of collection, anatomical location, morphological abnormalities of the anatomical location from which the material is taken, for example "wound" or "ulcer", etc. The SNOMED CT code system is proposed for most data.

Procedure

Type of procedure
Classification of the examination. Currently, the ERTN classification is used, for which the ÚZIS maintains a mapping to the codes of procedures of the VZP codebook. It is also proposed to use LOINC "Imaging Document Codes" or to also ensure mapping of the Czech Radiological Classification (ČRK) to LOINC.

Body part
Description of the part of the body, or laterality ("side"), on which the procedure is performed. Structured or at least free text.

Modality
Imaging modality (abbreviation) that performed the image recording. DICOM Standards PS 3.3-2011, section C.7.3.1.1.1

Reason for performance
Reason for performance of the procedure given by the healthcare professional responsible for performing the procedure. It may be different from that given in the request by the referring physician, or it supplements it.

Technique for performance of the procedure
Description of the technical implementation of the imaging method (e.g. used MR sequence, image projection, etc.). It also contains coded items. The description of the technical implementation can also be made in a formalized notation, i.e. structured, but at least (mandatory) in free text. The description of the technical implementation also contains information on the administration of substances, e.g. a substance or other medicinal contrast agent administered in connection with the procedure (e.g. contrast agent or sedative, etc.). At least the name of the medicinal product, dose and date and time of administration must be provided. If an adverse reaction occurs after administration, information on the adverse reaction must also be recorded.

Results
The description of the results of the performed procedures (examinations) must be at least free text and an observation code (SNOMED CT).

Conclusion
The conclusion summarizes the most important findings and/or diagnoses that were made based on the results of the imaging methods (possibly taking into account other clinical information). This section may contain a free text description of the clinical conclusion and/or a coded assessment, for example, a BI-RADS category or equivalent.

Recommendations
The recommendations may include, for example, recommendations for subsequent examinations or procedures that resulted from the results and/or conclusions. The structured part of this item is identical to the item of the same name in the discharge report.

Previous procedures

A reference to related previously performed imaging methods, e.g. for comparing results or trends, or to an older version of the Report changed by this report. The relevant report must belong to the same patient. The proposal does not prescribe the implementation method, how user information about previous examinations will be attached. A free text note is also possible.

Media (attachments)

Key images related to this report. There may be multiple attachments. In addition to metadata describing individual attached media, the attachment may contain the actual media content (inline) or a direct link to the source media. In addition to metadata, free text may be entered for the attachment. The proposal does not prescribe the implementation method, in which way the media will be attached by the user. The media, attachments, may also include outputs from devices in the form of images (e.g. ECG curves, microscope images, etc.) and also a trusted form of the document ("fingerprint" of the PDF/A document with a qualified signature).

DICOM metadata

Selected relevant data from the DICOM study without image data. The goal is to make the data available to all users without transferring entire DICOM image studies and without software enabling reading of DICOM data from image studies. Data that is part of DICOM is not overwritten, but is attached to the Report (into the Report) automatically. The "consumer" of the News receives information about the image study and can only get previews of some series, some images by "clicking through" from the news, etc.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition	C	0..*	Composition	Imaging Report composition Constraints: text-or-section
meta	Σ	0..1	Meta	Metadata about the resource
security	SΣ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:diagnosticreport-reference		1..1	Reference(Diagnostic Report: Imaging Report (CZ))	Document DiagnosticReport Reference URL: https://hl7.cz/fhir/img/StructureDefinition/im-composition-diagnosticReportReference
extension:basedOn-order-or-requisition		0..*	(Complex)	Composition: Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition"
Slices for value[x]		0..1		Value of extension Slice: Unordered, Open by type:$this
valueIdentifier			Identifier
valueReference			Reference(ServiceRequest)
value[x]:valueReference		0..1	Reference(Service Request: Imaging Report (CZ))	Value of extension
extension:basedOn		0..*	Reference(Resource)	Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:informationRecipient		0..*	(Complex)	Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/StructureDefinition/information-recipient"
value[x]		0..1	Reference(Practitioner (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Report identifier
status	?!Σ	1..1	code	Status of the Report 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.
subject	SΣ	1..1	Reference(Patient (CZ core))	Who and/or what the composition is about
date	SΣ	1..1	dateTime	Date the report was last changed.
author	Σ	1..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	Who and/or what authored the Imaging order
title	Σ	1..1	string	Human Readable name/title
Slices for attester	S	0..*	BackboneElement	Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
party		0..1	Reference(Patient (CZ core) | Related Person (CZ core) | Practitioner (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Who attested the composition
attester:legalAuthenticator	S	0..*	BackboneElement	Attests to accuracy of composition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
attester:resultValidator	S	0..*	BackboneElement	Attests to accuracy of composition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
custodian	SΣ	0..1	Reference(Organization (CZ core))	Organization that manages the Imaging Report
Slices for section	C	4..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	Who and/or what authored the section
section:imagingstudy	C	1..1	BackboneElement	Imaging Study Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18726-0
display		1..1	string	Representation defined by the system Fixed Value: Radiology studies (set)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	1..*	Reference(Imaging Study (CZ))	Imaging Study Reference
section:order	C	1..1	BackboneElement	Order Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55115-0
display		1..1	string	Representation defined by the system Fixed Value: Requested imaging studies information Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Service Request: Imaging Report (CZ))	Order reference
section:clinicalQuestion	C	0..*	BackboneElement	Clinical question Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18785-6
display		1..1	string	Representation defined by the system Fixed Value: Radiology Reason for study (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
text	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(Condition: Imaging Report (CZ))	A reference to data that supports this section
section:history	C	0..1	BackboneElement	History Constraints: cmp-1, cmp-2
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11329-0
display		1..1	string	Representation defined by the system Fixed Value: History general Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
section:procedure	C	1..1	BackboneElement	Procedure Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55111-9
display		1..1	string	Representation defined by the system Fixed Value: Current imaging procedure descriptions Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Procedure: Imaging Report (CZ))	A reference to data that supports this section
section:comparison	C	0..1	BackboneElement	Comparison Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18834-2
display		1..1	string	Representation defined by the system Fixed Value: Radiology Comparison study (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Imaging Study (CZ))	A reference to data that supports this section
section:findings	C	1..1	BackboneElement	Findings Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59776-5
display		1..1	string	Representation defined by the system Fixed Value: Procedure findings Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Observation: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	A reference to data that supports this section
section:impression	C	0..1	BackboneElement	Impressions Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 19005-8
display		1..1	string	Representation defined by the system Fixed Value: Radiology Imaging study [Impression] (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Observation: Imaging Report (CZ) | Condition: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	A reference to data that supports this section
section:recommendation	C	0..1	BackboneElement	Recommendations Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18783-1
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study recommendation (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
entry	C	0..*	Reference(Care plan: Imaging Report (CZ))	A reference to data that supports this section
section:communication	C	0..1	BackboneElement	Communications Constraints: cmp-1, cmp-2
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73575-3
display		1..1	string	Representation defined by the system Fixed Value: Radiology Consult note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.attester:legalAuthenticator.mode	required	Pattern Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.attester:resultValidator.mode	required	Pattern Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.section:imagingstudy.code	example	Pattern Value: LOINC Code 18726-0("Radiology studies (set)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:order.code	example	Pattern Value: LOINC Code 55115-0("Requested imaging studies information Document") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:clinicalQuestion.code	example	Pattern Value: LOINC Code 18785-6("Radiology Reason for study (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:history.code	example	Pattern Value: LOINC Code 11329-0("History general Narrative - Reported") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:procedure.code	example	Pattern Value: LOINC Code 55111-9("Current imaging procedure descriptions Document") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:comparison.code	example	Pattern Value: LOINC Code 18834-2("Radiology Comparison study (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:findings.code	example	Pattern Value: LOINC Code 59776-5("Procedure findings Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:impression.code	example	Pattern Value: LOINC Code 19005-8("Radiology Imaging study [Impression] (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:recommendation.code	example	Pattern Value: LOINC Code 18783-1("Radiology Study recommendation (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:communication.code	example	Pattern Value: LOINC Code 73575-3("Radiology Consult note") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:imagingstudy, Composition.section:order, Composition.section:clinicalQuestion, Composition.section:history, Composition.section:procedure, Composition.section:comparison, Composition.section:findings, Composition.section:impression, Composition.section:recommendation, Composition.section:communication	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:imagingstudy, Composition.section:order, Composition.section:clinicalQuestion, Composition.section:history, Composition.section:procedure, Composition.section:comparison, Composition.section:findings, Composition.section:impression, Composition.section:recommendation, Composition.section:communication	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
text-or-section	error	Composition	A Composition SHALL have either text, at least one section, or both. : text.exists() or section.exists()

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition	C	0..*	Composition	Imaging Report composition Constraints: text-or-section
meta
security	S	0..*	Coding	Security Labels applied to this resource
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:diagnosticreport-reference		1..1	Reference(Diagnostic Report: Imaging Report (CZ))	Document DiagnosticReport Reference URL: https://hl7.cz/fhir/img/StructureDefinition/im-composition-diagnosticReportReference
extension:basedOn-order-or-requisition		0..*	(Complex)	Composition: Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition
Slices for value[x]		0..1	Identifier, Reference(ServiceRequest)	Value of extension Slice: Unordered, Open by type:$this
value[x]:valueReference		0..1	Reference(Service Request: Imaging Report (CZ))	Value of extension
extension:basedOn		0..*	Reference(Resource)	Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:informationRecipient		0..*	(Complex)	Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
value[x]		0..1	Reference(Practitioner (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Value of extension
identifier		0..1	Identifier	Report identifier
status		1..1	code	Status of the Report
subject	S	1..1	Reference(Patient (CZ core))	Who and/or what the composition is about
date	S	1..1	dateTime	Date the report was last changed.
author		1..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	Who and/or what authored the Imaging order
Slices for attester	S	0..*	BackboneElement	Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices				Content/Rules for all slices
party		0..1	Reference(Patient (CZ core) | Related Person (CZ core) | Practitioner (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Who attested the composition
attester:legalAuthenticator	S	0..*	BackboneElement	Attests to accuracy of composition
mode	S	1..1	code	personal | professional | legal | official Required Pattern: legal
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
attester:resultValidator	S	0..*	BackboneElement	Attests to accuracy of composition
mode	S	1..1	code	personal | professional | legal | official Required Pattern: professional
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
custodian	S	0..1	Reference(Organization (CZ core))	Organization that manages the Imaging Report
Slices for section		4..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code
section:All Slices				Content/Rules for all slices
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	Who and/or what authored the section
section:imagingstudy		1..1	BackboneElement	Imaging Study
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18726-0
display		1..1	string	Representation defined by the system Fixed Value: Radiology studies (set)
entry		1..*	Reference(Imaging Study (CZ))	Imaging Study Reference
section:order		1..1	BackboneElement	Order
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55115-0
display		1..1	string	Representation defined by the system Fixed Value: Requested imaging studies information Document
entry		0..*	Reference(Service Request: Imaging Report (CZ))	Order reference
section:clinicalQuestion		0..*	BackboneElement	Clinical question
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18785-6
display		1..1	string	Representation defined by the system Fixed Value: Radiology Reason for study (narrative)
text		1..1	Narrative	Text summary of the section, for human interpretation
entry		0..*	Reference(Condition: Imaging Report (CZ))	A reference to data that supports this section
section:history		0..1	BackboneElement	History
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11329-0
display		1..1	string	Representation defined by the system Fixed Value: History general Narrative - Reported
section:procedure		1..1	BackboneElement	Procedure
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55111-9
display		1..1	string	Representation defined by the system Fixed Value: Current imaging procedure descriptions Document
entry		0..*	Reference(Procedure: Imaging Report (CZ))	A reference to data that supports this section
section:comparison		0..1	BackboneElement	Comparison
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18834-2
display		1..1	string	Representation defined by the system Fixed Value: Radiology Comparison study (narrative)
entry		0..*	Reference(Imaging Study (CZ))	A reference to data that supports this section
section:findings		1..1	BackboneElement	Findings
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59776-5
display		1..1	string	Representation defined by the system Fixed Value: Procedure findings Narrative
entry		0..*	Reference(Observation: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	A reference to data that supports this section
section:impression		0..1	BackboneElement	Impressions
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 19005-8
display		1..1	string	Representation defined by the system Fixed Value: Radiology Imaging study [Impression] (narrative)
entry		0..*	Reference(Observation: Imaging Report (CZ) | Condition: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	A reference to data that supports this section
section:recommendation		0..1	BackboneElement	Recommendations
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18783-1
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study recommendation (narrative)
entry		0..*	Reference(Care plan: Imaging Report (CZ))	A reference to data that supports this section
section:communication		0..1	BackboneElement	Communications
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
code		1..1	CodeableConcept	Classification of section (recommended) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73575-3
display		1..1	string	Representation defined by the system Fixed Value: Radiology Consult note
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
text-or-section	error	Composition	A Composition SHALL have either text, at least one section, or both. : text.exists() or section.exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition	C	0..*	Composition	Imaging Report composition Constraints: text-or-section
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	SΣ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:diagnosticreport-reference		1..1	Reference(Diagnostic Report: Imaging Report (CZ))	Document DiagnosticReport Reference URL: https://hl7.cz/fhir/img/StructureDefinition/im-composition-diagnosticReportReference
extension:basedOn-order-or-requisition		0..*	(Complex)	Composition: Based On Order URL: http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition
id		0..1	id	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition"
Slices for value[x]		0..1		Value of extension Slice: Unordered, Open by type:$this
valueIdentifier			Identifier
valueReference			Reference(ServiceRequest)
value[x]:valueReference		0..1	Reference(Service Request: Imaging Report (CZ))	Value of extension
extension:basedOn		0..*	Reference(Resource)	Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:informationRecipient		0..*	(Complex)	Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
id		0..1	id	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/StructureDefinition/information-recipient"
value[x]		0..1	Reference(Practitioner (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Report identifier
status	?!Σ	1..1	code	Status of the Report 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.
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient (CZ core))	Who and/or what the composition is about
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Date the report was last changed.
author	Σ	1..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	Who and/or what authored the Imaging order
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
Slices for attester	S	0..*	BackboneElement	Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient (CZ core) | Related Person (CZ core) | Practitioner (CZ core) | Practitioner Role (CZ core) | Organization (CZ core))	Who attested the composition
attester:legalAuthenticator	S	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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: legal
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
attester:resultValidator	S	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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Required Pattern: professional
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Practitioner Role (CZ core))	Who attested the composition
custodian	SΣ	0..1	Reference(Organization (CZ core))	Organization that manages the Imaging Report
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	C	4..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:imagingstudy	C	1..1	BackboneElement	Imaging Study Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18726-0
display		1..1	string	Representation defined by the system Fixed Value: Radiology studies (set)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	1..*	Reference(Imaging Study (CZ))	Imaging Study Reference
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:order	C	1..1	BackboneElement	Order Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55115-0
display		1..1	string	Representation defined by the system Fixed Value: Requested imaging studies information Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Service Request: Imaging Report (CZ))	Order reference
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:clinicalQuestion	C	0..*	BackboneElement	Clinical question Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18785-6
display		1..1	string	Representation defined by the system Fixed Value: Radiology Reason for study (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	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
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Condition: Imaging Report (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:history	C	0..1	BackboneElement	History Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 11329-0
display		1..1	string	Representation defined by the system Fixed Value: History general Narrative - Reported
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:procedure	C	1..1	BackboneElement	Procedure Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 55111-9
display		1..1	string	Representation defined by the system Fixed Value: Current imaging procedure descriptions Document
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Procedure: Imaging Report (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:comparison	C	0..1	BackboneElement	Comparison Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18834-2
display		1..1	string	Representation defined by the system Fixed Value: Radiology Comparison study (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Imaging Study (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:findings	C	1..1	BackboneElement	Findings Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 59776-5
display		1..1	string	Representation defined by the system Fixed Value: Procedure findings Narrative
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Observation: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:impression	C	0..1	BackboneElement	Impressions Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 19005-8
display		1..1	string	Representation defined by the system Fixed Value: Radiology Imaging study [Impression] (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Observation: Imaging Report (CZ) | Condition: Imaging Report (CZ) | Imaging Key Image Document Reference: Imaging Report (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:recommendation	C	0..1	BackboneElement	Recommendations Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18783-1
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study recommendation (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Care plan: Imaging Report (CZ))	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	C	0..*	See section (Composition)	Nested Section
section:communication	C	0..1	BackboneElement	Communications Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:note		0..*	Annotation	Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73575-3
display		1..1	string	Representation defined by the system Fixed Value: Radiology Consult note
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner (CZ core) | Practitioner Role (CZ core) | Device: Performer/Observer (CZ) | Patient (CZ core) | Related Person (CZ core) | Organization (CZ core))	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	C	0..1	Narrative	Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
Composition.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 From the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.attester:legalAuthenticator.mode	required	Pattern Value: legal http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.attester:resultValidator.mode	required	Pattern Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode|3.0.0
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:imagingstudy.code	example	Pattern Value: LOINC Code 18726-0("Radiology studies (set)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:imagingstudy.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:imagingstudy.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:imagingstudy.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:order.code	example	Pattern Value: LOINC Code 55115-0("Requested imaging studies information Document") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:order.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:order.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:order.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:clinicalQuestion.code	example	Pattern Value: LOINC Code 18785-6("Radiology Reason for study (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:clinicalQuestion.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:clinicalQuestion.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:clinicalQuestion.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:history.code	example	Pattern Value: LOINC Code 11329-0("History general Narrative - Reported") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:history.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:history.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:history.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:procedure.code	example	Pattern Value: LOINC Code 55111-9("Current imaging procedure descriptions Document") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:procedure.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:procedure.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:procedure.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:comparison.code	example	Pattern Value: LOINC Code 18834-2("Radiology Comparison study (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:comparison.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:comparison.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:comparison.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:findings.code	example	Pattern Value: LOINC Code 59776-5("Procedure findings Narrative") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:findings.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:findings.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:findings.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:impression.code	example	Pattern Value: LOINC Code 19005-8("Radiology Imaging study [Impression] (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:impression.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:impression.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:impression.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:recommendation.code	example	Pattern Value: LOINC Code 18783-1("Radiology Study recommendation (narrative)") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:recommendation.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:recommendation.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:recommendation.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard
Composition.section:communication.code	example	Pattern Value: LOINC Code 73575-3("Radiology Consult note") http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section:communication.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section:communication.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section:communication.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section, Composition.section:imagingstudy, Composition.section:order, Composition.section:clinicalQuestion, Composition.section:history, Composition.section:procedure, Composition.section:comparison, Composition.section:findings, Composition.section:impression, Composition.section:recommendation, Composition.section:communication	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section, Composition.section:imagingstudy, Composition.section:order, Composition.section:clinicalQuestion, Composition.section:history, Composition.section:procedure, Composition.section:comparison, Composition.section:findings, Composition.section:impression, Composition.section:recommendation, Composition.section:communication	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
text-or-section	error	Composition	A Composition SHALL have either text, at least one section, or both. : text.exists() or section.exists()