Dental Data Exchange, published by Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/dental-data-exchange/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note | Version: 2.0.0-ballot | |||
Active as of 2020-08-10 | Computable Name: DentalConsultNote |
This Profile defines the Dental Consult Note profile. It contains the textual information regarding what was observed and performed by a general dentist or dental specialist in response to a dental referral as well as references to supplemental dental profiles for that referral. This Consult Note is linked to its Referral via the In-Fulfillment-Of extension reference to ServiceRequest.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ConsultationNote
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |
Slices for extension | Content/Rules for all slices | |||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |
value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension |
type | S | 1..1 | CodeableConcept | Dentistry Consult note 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: 34756-7 | |
encounter | S | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
section:assessment_section | 1..1 | BackboneElement | Assessment Section | |
section:plan_of_treatment_section | 1..1 | BackboneElement | Plan of Treatment Section | |
entry | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry | |
section:procedures_section | 1..1 | BackboneElement | Procedures Section | |
section:reason_for_visit_section | 1..1 | BackboneElement | Reason for Visit Section | |
section:instructions | S | 0..1 | BackboneElement | Composition is broken into sections |
title | S | 1..1 | string | title |
code | S | 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: 69730-0 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:dental_instructions | S | 0..* | Reference(Dental Communication) | A reference to data that supports this section |
section:payers_section | 0..1 | BackboneElement | Composition is broken into sections | |
code | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:payers_entry | 0..* | Reference(HRex Coverage Profile) | A reference to data that supports this section | |
section:dental_findings_section | S | 0..1 | BackboneElement | Composition is broken into sections |
title | S | 1..1 | string | title |
code | S | 0..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: 8704-9 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:dental_findings_entry | S | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | A reference to data that supports this section |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
Slices for extension | Content/Rules for all slices | |||||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
informant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0)) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
participant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
performer_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |||||
Slices for value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension Slice: Unordered, Closed by type:$this | ||||
value[x]:valueReference | S | 1..1 | Reference(ServiceRequest) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 1..1 | Identifier | identifier | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Dentistry Consult note Binding: ConsultDocumentType (required) 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: 34756-7 | |||||
subject | SΣ | 0..1 | Reference(US Core Patient Profile(4.0.0) | Group) | Who and/or what the composition is about | ||||
encounter | SΣ | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter | ||||
date | SΣ | 1..1 | dateTime | date | ||||
author | SΣ | 1..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | PractitionerRole | US Core Patient Profile(4.0.0) | Device | RelatedPerson) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Document Title | ||||
Slices for attester | 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. | |||||
attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
party | S | 1..1 | Reference(US Core Patient Profile(4.0.0) | RelatedPerson) | party | ||||
custodian | SΣ | 1..1 | Reference(US Core Organization Profile(4.0.0)) | custodian | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
section:allergies_and_intolerances_section | SC | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Allergies and adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
text | SC | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:allergy_intolerance_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile(4.0.0)) | A reference to data that supports this section | ||||
section:history_of_present_illness_section | SC | 1..1 | BackboneElement | History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | History of present illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10164-2 | |||||
text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
section:problem_section | C | 1..1 | BackboneElement | Problem Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:problem_section_entry | SC | 0..* | Reference(US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
section:medications_section | C | 0..1 | BackboneElement | Medications Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(MedicationStatement | US Core Medication Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0)) | A reference to data that supports this section | ||||
section:physical_exam_section | C | 0..1 | BackboneElement | Physical Exam Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29545-1 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:results_section | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Relevant diagnostic tests/laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 30954-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Laboratory Result Observation Profile(4.0.0)) | A reference to data that supports this section | ||||
section:advance_directives_section | SC | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 42348-3 | |||||
text | SC | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:advance_directive_entry | SC | 0..* | Reference(Consent) | A reference to data that supports this section | ||||
section:assessment_and_plan_section | C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessment (evaluation) and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 51847-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0) | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:assessment_section | C | 1..1 | BackboneElement | Assessment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessments (evaluation) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 51848-0 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:chief_complaint_and_reason_for_visit_section | C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint and reason for visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 46239-0 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:chief_complaint_section | C | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10154-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:family_history_section | C | 0..1 | BackboneElement | Family History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Family history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10157-6 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:functional_status_section | C | 0..1 | BackboneElement | Functional Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Functional status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 47420-5 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:general_status_section | C | 0..1 | BackboneElement | General Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings of General status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10210-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:past_medical_history_section | C | 0..1 | BackboneElement | Past Medical History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Past Medical History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 11348-0 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
section:immunizations_section | C | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 11369-6 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Immunization Profile(4.0.0)) | A reference to data that supports this section | ||||
section:medical_equipment_section | C | 0..1 | BackboneElement | Medical Equipment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medical device use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 46264-8 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:medical_equipment_entry | SC | 0..* | Reference(Device | US Core Procedure Profile(4.0.0)) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:mental_status_section | C | 0..1 | BackboneElement | Mental Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Mental status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10190-7 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:nutrition_section | C | 0..1 | BackboneElement | Nutrition Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 61144-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(NutritionOrder | ClinicalImpression) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:plan_of_treatment_section | C | 1..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 18776-5 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:procedures_section | C | 1..1 | BackboneElement | Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 47519-4 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Procedure Profile(4.0.0)) | A reference to data that supports this section | ||||
section:reason_for_visit_section | C | 1..1 | BackboneElement | Reason for Visit Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Reason for visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29299-5 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:review_of_systems_section | C | 0..1 | BackboneElement | Review of Systems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10187-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:social_history_section | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29762-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Smoking Status Observation Profile(4.0.0)) | Smoking status | ||||
section:vital_signs_section | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8716-3 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | ||||
section:instructions | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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: 69730-0 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_instructions | SC | 0..* | Reference(Dental Communication) | A reference to data that supports this section | ||||
section:payers_section | C | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:payers_entry | C | 0..* | Reference(HRex Coverage Profile) | A reference to data that supports this section | ||||
section:dental_findings_section | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8704-9 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_findings_entry | SC | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | required | Pattern: LOINC Code 34756-7http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.31 | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:problem_section.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medications_section.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:physical_exam_section.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:results_section.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:advance_directives_section.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC Code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_section.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC Code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_section.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:family_history_section.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:functional_status_section.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:general_status_section.code | example | Pattern: LOINC Code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:past_medical_history_section.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:immunizations_section.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medical_equipment_section.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:mental_status_section.code | example | Pattern: LOINC Code 10190-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:nutrition_section.code | example | Pattern: LOINC Code 61144-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:procedures_section.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:review_of_systems_section.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:social_history_section.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:vital_signs_section.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:instructions.code | example | Pattern: LOINC Code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:payers_section.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dental_findings_section.code | example | Pattern: LOINC Code 8704-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
informant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0)) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
participant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
performer_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |||||
Slices for value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension Slice: Unordered, Closed by type:$this | ||||
value[x]:valueReference | S | 1..1 | Reference(ServiceRequest) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 1..1 | Identifier | identifier | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Dentistry Consult note Binding: ConsultDocumentType (required) 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: 34756-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 0..1 | Reference(US Core Patient Profile(4.0.0) | Group) | Who and/or what the composition is about | ||||
encounter | SΣ | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter | ||||
date | SΣ | 1..1 | dateTime | date | ||||
author | SΣ | 1..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | PractitionerRole | US Core Patient Profile(4.0.0) | Device | RelatedPerson) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Document Title | ||||
Slices for attester | 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 | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Patient Profile(4.0.0) | RelatedPerson) | party | ||||
custodian | SΣ | 1..1 | Reference(US Core Organization Profile(4.0.0)) | custodian | ||||
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: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
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:allergies_and_intolerances_section | SC | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Allergies and adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:allergy_intolerance_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile(4.0.0)) | 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_of_present_illness_section | SC | 1..1 | BackboneElement | History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | History of present illness 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: 10164-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
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:problem_section | C | 1..1 | BackboneElement | Problem Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:problem_section_entry | SC | 0..* | Reference(US Core Condition Profile(4.0.0)) | 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:medications_section | C | 0..1 | BackboneElement | Medications Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(MedicationStatement | US Core Medication Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0)) | 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:physical_exam_section | C | 0..1 | BackboneElement | Physical Exam Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings 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: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:results_section | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Relevant diagnostic tests/laboratory data 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: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Laboratory Result Observation Profile(4.0.0)) | 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:advance_directives_section | SC | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Advance directives 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: 42348-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:advance_directive_entry | SC | 0..* | Reference(Consent) | 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:assessment_and_plan_section | C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessment (evaluation) and plan 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: 51847-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0) | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:assessment_section | C | 1..1 | BackboneElement | Assessment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessments (evaluation) 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: 51848-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:chief_complaint_and_reason_for_visit_section | C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint and reason for visit 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: 46239-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:chief_complaint_section | C | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint 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: 10154-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:family_history_section | C | 0..1 | BackboneElement | Family History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Family history 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: 10157-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:functional_status_section | C | 0..1 | BackboneElement | Functional Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Functional status 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: 47420-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:general_status_section | C | 0..1 | BackboneElement | General Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings of General status 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: 10210-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:past_medical_history_section | C | 0..1 | BackboneElement | Past Medical History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Past Medical History 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: 11348-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0)) | 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:immunizations_section | C | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of immunization 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: 11369-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Immunization Profile(4.0.0)) | 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:medical_equipment_section | C | 0..1 | BackboneElement | Medical Equipment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medical device use 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: 46264-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:medical_equipment_entry | SC | 0..* | Reference(Device | US Core Procedure Profile(4.0.0)) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:mental_status_section | C | 0..1 | BackboneElement | Mental Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Mental status 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: 10190-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:nutrition_section | C | 0..1 | BackboneElement | Nutrition Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Diet and nutrition 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: 61144-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(NutritionOrder | ClinicalImpression) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:plan_of_treatment_section | C | 1..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Plan of treatment 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: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:procedures_section | C | 1..1 | BackboneElement | Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of Procedures 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: 47519-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Procedure Profile(4.0.0)) | 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:reason_for_visit_section | C | 1..1 | BackboneElement | Reason for Visit Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Reason for visit 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: 29299-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:review_of_systems_section | C | 0..1 | BackboneElement | Review of Systems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Review of systems 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: 10187-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:social_history_section | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Social history 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: 29762-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Smoking Status Observation Profile(4.0.0)) | Smoking status | ||||
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:vital_signs_section | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Vital signs 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: 8716-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Vital Signs Profile) | 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:instructions | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_instructions | SC | 0..* | Reference(Dental Communication) | 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:payers_section | C | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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: 48768-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:payers_entry | C | 0..* | Reference(HRex Coverage Profile) | 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:dental_findings_section | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 0..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: 8704-9 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_findings_entry | SC | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | 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 |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | required | Pattern: LOINC Code 34756-7http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.31 | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | v3.ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode from the FHIR Standard | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:problem_section.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:problem_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:problem_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:problem_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:medications_section.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:medications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:medications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:physical_exam_section.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:physical_exam_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:results_section.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:results_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:results_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:results_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:advance_directives_section.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:advance_directives_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:advance_directives_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:advance_directives_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC Code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:assessment_section.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:assessment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC Code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:chief_complaint_section.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:chief_complaint_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:family_history_section.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:family_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:family_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:functional_status_section.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:functional_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:functional_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:functional_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:general_status_section.code | example | Pattern: LOINC Code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:general_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:general_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:past_medical_history_section.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:past_medical_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:immunizations_section.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:immunizations_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:medical_equipment_section.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medical_equipment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:medical_equipment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:medical_equipment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:mental_status_section.code | example | Pattern: LOINC Code 10190-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:mental_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:mental_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:mental_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:nutrition_section.code | example | Pattern: LOINC Code 61144-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:nutrition_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:nutrition_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:nutrition_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:procedures_section.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:procedures_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:procedures_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:review_of_systems_section.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:review_of_systems_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:social_history_section.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:social_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:social_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:vital_signs_section.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:vital_signs_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:instructions.code | example | Pattern: LOINC Code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:instructions.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:instructions.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:instructions.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:payers_section.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:payers_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:payers_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:payers_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dental_findings_section.code | example | Pattern: LOINC Code 8704-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dental_findings_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dental_findings_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dental_findings_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
This structure is derived from ConsultationNote
Summary
Mandatory: 5 elements(4 nested mandatory elements)
Must-Support: 12 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ConsultationNote
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |
Slices for extension | Content/Rules for all slices | |||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension |
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |
value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension |
type | S | 1..1 | CodeableConcept | Dentistry Consult note 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: 34756-7 | |
encounter | S | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
section:assessment_section | 1..1 | BackboneElement | Assessment Section | |
section:plan_of_treatment_section | 1..1 | BackboneElement | Plan of Treatment Section | |
entry | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry | |
section:procedures_section | 1..1 | BackboneElement | Procedures Section | |
section:reason_for_visit_section | 1..1 | BackboneElement | Reason for Visit Section | |
section:instructions | S | 0..1 | BackboneElement | Composition is broken into sections |
title | S | 1..1 | string | title |
code | S | 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: 69730-0 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:dental_instructions | S | 0..* | Reference(Dental Communication) | A reference to data that supports this section |
section:payers_section | 0..1 | BackboneElement | Composition is broken into sections | |
code | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:payers_entry | 0..* | Reference(HRex Coverage Profile) | A reference to data that supports this section | |
section:dental_findings_section | S | 0..1 | BackboneElement | Composition is broken into sections |
title | S | 1..1 | string | title |
code | S | 0..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: 8704-9 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry:dental_findings_entry | S | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | A reference to data that supports this section |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
Slices for extension | Content/Rules for all slices | |||||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
informant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0)) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
participant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
performer_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |||||
Slices for value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension Slice: Unordered, Closed by type:$this | ||||
value[x]:valueReference | S | 1..1 | Reference(ServiceRequest) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 1..1 | Identifier | identifier | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Dentistry Consult note Binding: ConsultDocumentType (required) 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: 34756-7 | |||||
subject | SΣ | 0..1 | Reference(US Core Patient Profile(4.0.0) | Group) | Who and/or what the composition is about | ||||
encounter | SΣ | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter | ||||
date | SΣ | 1..1 | dateTime | date | ||||
author | SΣ | 1..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | PractitionerRole | US Core Patient Profile(4.0.0) | Device | RelatedPerson) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Document Title | ||||
Slices for attester | 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. | |||||
attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | S | 1..1 | code | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
party | S | 1..1 | Reference(US Core Patient Profile(4.0.0) | RelatedPerson) | party | ||||
custodian | SΣ | 1..1 | Reference(US Core Organization Profile(4.0.0)) | custodian | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
section:allergies_and_intolerances_section | SC | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Allergies and adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
text | SC | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:allergy_intolerance_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile(4.0.0)) | A reference to data that supports this section | ||||
section:history_of_present_illness_section | SC | 1..1 | BackboneElement | History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | History of present illness Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10164-2 | |||||
text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
section:problem_section | C | 1..1 | BackboneElement | Problem Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:problem_section_entry | SC | 0..* | Reference(US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
section:medications_section | C | 0..1 | BackboneElement | Medications Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(MedicationStatement | US Core Medication Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0)) | A reference to data that supports this section | ||||
section:physical_exam_section | C | 0..1 | BackboneElement | Physical Exam Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29545-1 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:results_section | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Relevant diagnostic tests/laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 30954-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Laboratory Result Observation Profile(4.0.0)) | A reference to data that supports this section | ||||
section:advance_directives_section | SC | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Advance directives Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 42348-3 | |||||
text | SC | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:advance_directive_entry | SC | 0..* | Reference(Consent) | A reference to data that supports this section | ||||
section:assessment_and_plan_section | C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessment (evaluation) and plan Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 51847-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0) | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:assessment_section | C | 1..1 | BackboneElement | Assessment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessments (evaluation) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 51848-0 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:chief_complaint_and_reason_for_visit_section | C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint and reason for visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 46239-0 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:chief_complaint_section | C | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10154-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:family_history_section | C | 0..1 | BackboneElement | Family History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Family history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10157-6 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:functional_status_section | C | 0..1 | BackboneElement | Functional Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Functional status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 47420-5 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:general_status_section | C | 0..1 | BackboneElement | General Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings of General status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10210-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:past_medical_history_section | C | 0..1 | BackboneElement | Past Medical History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Past Medical History Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 11348-0 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
section:immunizations_section | C | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of immunization Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 11369-6 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Immunization Profile(4.0.0)) | A reference to data that supports this section | ||||
section:medical_equipment_section | C | 0..1 | BackboneElement | Medical Equipment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medical device use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 46264-8 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:medical_equipment_entry | SC | 0..* | Reference(Device | US Core Procedure Profile(4.0.0)) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:mental_status_section | C | 0..1 | BackboneElement | Mental Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Mental status Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10190-7 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:nutrition_section | C | 0..1 | BackboneElement | Nutrition Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Diet and nutrition Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 61144-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(NutritionOrder | ClinicalImpression) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:plan_of_treatment_section | C | 1..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Plan of treatment Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 18776-5 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
section:procedures_section | C | 1..1 | BackboneElement | Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of Procedures Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 47519-4 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Procedure Profile(4.0.0)) | A reference to data that supports this section | ||||
section:reason_for_visit_section | C | 1..1 | BackboneElement | Reason for Visit Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Reason for visit Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29299-5 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:review_of_systems_section | C | 0..1 | BackboneElement | Review of Systems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Review of systems Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 10187-3 | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
section:social_history_section | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Social history Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 29762-2 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Smoking Status Observation Profile(4.0.0)) | Smoking status | ||||
section:vital_signs_section | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Vital signs Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8716-3 | |||||
text | C | 1..1 | Narrative | text | ||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | ||||
section:instructions | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
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: 69730-0 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_instructions | SC | 0..* | Reference(Dental Communication) | A reference to data that supports this section | ||||
section:payers_section | C | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:payers_entry | C | 0..* | Reference(HRex Coverage Profile) | A reference to data that supports this section | ||||
section:dental_findings_section | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | title | ||||
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8704-9 | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_findings_entry | SC | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | A reference to data that supports this section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | required | Pattern: LOINC Code 34756-7http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.31 | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:problem_section.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medications_section.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:physical_exam_section.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:results_section.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:advance_directives_section.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC Code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_section.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC Code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_section.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:family_history_section.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:functional_status_section.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:general_status_section.code | example | Pattern: LOINC Code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:past_medical_history_section.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:immunizations_section.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medical_equipment_section.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:mental_status_section.code | example | Pattern: LOINC Code 10190-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:nutrition_section.code | example | Pattern: LOINC Code 61144-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:procedures_section.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:review_of_systems_section.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:social_history_section.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:vital_signs_section.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:instructions.code | example | Pattern: LOINC Code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:payers_section.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dental_findings_section.code | example | Pattern: LOINC Code 8704-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | ConsultationNote | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | S | 1..1 | code | language Binding: CommonLanguages (preferred): A human language.
| ||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
version_number_extension | S | 0..1 | integer | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber | ||||
data_enterer_extension | S | 0..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension | ||||
informant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | informant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension | ||||
information_recipient_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0)) | informationRecipient URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension | ||||
participant_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | US Core Patient Profile(4.0.0) | RelatedPerson) | participant URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension | ||||
performer_extension | S | 0..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | performer URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension | ||||
authorization_extension | S | 0..* | Reference(Consent) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension | ||||
order_extension | S | 0..* | (Complex) | authorization URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
url | 1..1 | uri | "http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension" | |||||
Slices for value[x] | S | 1..1 | Reference(Dental Service Request) | Value of extension Slice: Unordered, Closed by type:$this | ||||
value[x]:valueReference | S | 1..1 | Reference(ServiceRequest) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 1..1 | Identifier | identifier | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Dentistry Consult note Binding: ConsultDocumentType (required) 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: 34756-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 0..1 | Reference(US Core Patient Profile(4.0.0) | Group) | Who and/or what the composition is about | ||||
encounter | SΣ | 1..1 | Reference(US Core Encounter Profile(4.0.0)) | encompassingEncounter | ||||
date | SΣ | 1..1 | dateTime | date | ||||
author | SΣ | 1..* | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0) | PractitionerRole | US Core Patient Profile(4.0.0) | Device | RelatedPerson) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Document Title | ||||
Slices for attester | 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 | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
attester:legal_attester | S | 0..1 | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: legal | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:professional_attester | S | 0..* | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Practitioner Profile(4.0.0) | US Core PractitionerRole Profile(4.0.0)) | party | ||||
attester:personal_attester | S | 0..* | BackboneElement | attester | ||||
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 | mode Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: personal | ||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | S | 1..1 | Reference(US Core Patient Profile(4.0.0) | RelatedPerson) | party | ||||
custodian | SΣ | 1..1 | Reference(US Core Organization Profile(4.0.0)) | custodian | ||||
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: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
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:allergies_and_intolerances_section | SC | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Allergies and adverse reactions Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:allergy_intolerance_entry | SC | 0..* | Reference(US Core AllergyIntolerance Profile(4.0.0)) | 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_of_present_illness_section | SC | 1..1 | BackboneElement | History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | History of present illness 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: 10164-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | This section contains only human readable content | ||||
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:problem_section | C | 1..1 | BackboneElement | Problem Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:problem_section_entry | SC | 0..* | Reference(US Core Condition Profile(4.0.0)) | 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:medications_section | C | 0..1 | BackboneElement | Medications Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(MedicationStatement | US Core Medication Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0)) | 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:physical_exam_section | C | 0..1 | BackboneElement | Physical Exam Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings 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: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:results_section | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Relevant diagnostic tests/laboratory data 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: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Laboratory Result Observation Profile(4.0.0)) | 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:advance_directives_section | SC | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Advance directives 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: 42348-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | SC | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:advance_directive_entry | SC | 0..* | Reference(Consent) | 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:assessment_and_plan_section | C | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessment (evaluation) and plan 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: 51847-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0) | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:assessment_section | C | 1..1 | BackboneElement | Assessment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Assessments (evaluation) 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: 51848-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:chief_complaint_and_reason_for_visit_section | C | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint and reason for visit 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: 46239-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:chief_complaint_section | C | 0..1 | BackboneElement | Chief Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Chief complaint 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: 10154-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:family_history_section | C | 0..1 | BackboneElement | Family History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Family history 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: 10157-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:functional_status_section | C | 0..1 | BackboneElement | Functional Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Functional status 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: 47420-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:general_status_section | C | 0..1 | BackboneElement | General Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Physical findings of General status 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: 10210-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:past_medical_history_section | C | 0..1 | BackboneElement | Past Medical History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Past Medical History 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: 11348-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Condition Profile(4.0.0)) | 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:immunizations_section | C | 0..1 | BackboneElement | Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of immunization 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: 11369-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Immunization Profile(4.0.0)) | 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:medical_equipment_section | C | 0..1 | BackboneElement | Medical Equipment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of medical device use 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: 46264-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:medical_equipment_entry | SC | 0..* | Reference(Device | US Core Procedure Profile(4.0.0)) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:mental_status_section | C | 0..1 | BackboneElement | Mental Status Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Mental status 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: 10190-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:nutrition_section | C | 0..1 | BackboneElement | Nutrition Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Diet and nutrition 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: 61144-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(NutritionOrder | ClinicalImpression) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:plan_of_treatment_section | C | 1..1 | BackboneElement | Plan of Treatment Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Plan of treatment 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: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Dental Service Request | Dental Communication | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Appointment | US Core Goal Profile(4.0.0) | CommunicationRequest | DeviceRequest | NutritionOrder | Task | VisionPrescription | RequestGroup) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Goal Profile(4.0.0) | US Core MedicationRequest Profile(4.0.0) | US Core Encounter Profile(4.0.0) | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | ||||
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:procedures_section | C | 1..1 | BackboneElement | Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | History of Procedures 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: 47519-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Procedure Profile(4.0.0)) | 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:reason_for_visit_section | C | 1..1 | BackboneElement | Reason for Visit Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Reason for visit 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: 29299-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:review_of_systems_section | C | 0..1 | BackboneElement | Review of Systems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Review of systems 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: 10187-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | This section contains only human readable content | ||||
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:social_history_section | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Social history 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: 29762-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(US Core Smoking Status Observation Profile(4.0.0)) | Smoking status | ||||
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:vital_signs_section | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..1 | string | title | |||||
code | 1..1 | CodeableConcept | Vital signs 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: 8716-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | text | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | ||||
entry:sliceEntry | C | 0..* | Reference(Vital Signs Profile) | 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:instructions | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_instructions | SC | 0..* | Reference(Dental Communication) | 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:payers_section | C | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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: 48768-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:payers_entry | C | 0..* | Reference(HRex Coverage Profile) | 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:dental_findings_section | SC | 0..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | string | title | ||||
code | S | 0..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: 8704-9 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
entry:dental_findings_entry | SC | 0..* | Reference(Dental Findings | US Core Condition Profile(4.0.0)) | 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 |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | required | Pattern: LOINC Code 34756-7http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.31 | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:legal_attester.mode | required | Fixed Value: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:professional_attester.mode | required | Fixed Value: professionalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.attester:personal_attester.mode | required | Fixed Value: personalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | v3.ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode from the FHIR Standard | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:allergies_and_intolerances_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:history_of_present_illness_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:problem_section.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:problem_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:problem_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:problem_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:medications_section.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medications_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:medications_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:medications_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:physical_exam_section.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:physical_exam_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:physical_exam_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:physical_exam_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:results_section.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:results_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:results_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:results_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:advance_directives_section.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:advance_directives_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:advance_directives_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:advance_directives_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.code | example | Pattern: LOINC Code 51847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:assessment_and_plan_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:assessment_section.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:assessment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:assessment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:assessment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.code | example | Pattern: LOINC Code 46239-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:chief_complaint_section.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:chief_complaint_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:chief_complaint_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:chief_complaint_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:family_history_section.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:family_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:family_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:family_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:functional_status_section.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:functional_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:functional_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:functional_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:general_status_section.code | example | Pattern: LOINC Code 10210-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:general_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:general_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:general_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:past_medical_history_section.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:past_medical_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:past_medical_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:past_medical_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:immunizations_section.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:immunizations_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:immunizations_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:immunizations_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:medical_equipment_section.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:medical_equipment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:medical_equipment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:medical_equipment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:mental_status_section.code | example | Pattern: LOINC Code 10190-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:mental_status_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:mental_status_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:mental_status_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:nutrition_section.code | example | Pattern: LOINC Code 61144-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:nutrition_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:nutrition_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:nutrition_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:plan_of_treatment_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:procedures_section.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:procedures_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:procedures_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:procedures_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:reason_for_visit_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:review_of_systems_section.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:review_of_systems_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:review_of_systems_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:review_of_systems_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:social_history_section.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:social_history_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:social_history_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:social_history_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:vital_signs_section.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:vital_signs_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:vital_signs_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:vital_signs_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:instructions.code | example | Pattern: LOINC Code 69730-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:instructions.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:instructions.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:instructions.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:payers_section.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:payers_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:payers_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:payers_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dental_findings_section.code | example | Pattern: LOINC Code 8704-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dental_findings_section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dental_findings_section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dental_findings_section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:allergies_and_intolerances_section, Composition.section:history_of_present_illness_section, Composition.section:problem_section, Composition.section:medications_section, Composition.section:physical_exam_section, Composition.section:results_section, Composition.section:advance_directives_section, Composition.section:assessment_and_plan_section, Composition.section:assessment_section, Composition.section:chief_complaint_and_reason_for_visit_section, Composition.section:chief_complaint_section, Composition.section:family_history_section, Composition.section:functional_status_section, Composition.section:general_status_section, Composition.section:past_medical_history_section, Composition.section:immunizations_section, Composition.section:medical_equipment_section, Composition.section:mental_status_section, Composition.section:nutrition_section, Composition.section:plan_of_treatment_section, Composition.section:procedures_section, Composition.section:reason_for_visit_section, Composition.section:review_of_systems_section, Composition.section:social_history_section, Composition.section:vital_signs_section, Composition.section:instructions, Composition.section:payers_section, Composition.section:dental_findings_section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
This structure is derived from ConsultationNote
Summary
Mandatory: 5 elements(4 nested mandatory elements)
Must-Support: 12 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron