FHIR Clinical Documents
1.0.0-ballot - STU1 Ballot
FHIR Clinical Documents
1.0.0-ballot - STU1 Ballot
FHIR Clinical Documents, published by HL7 International / Structured Documents. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-clinical-document/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | Version: 1.0.0-ballot | |||
| Draft as of 2024-08-07 | Maturity Level: 2 | Computable Name: DataEntererExtension | ||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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The Data Enterer Extension represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
Context of Use
This extension may be used on the following element(s):
Usage info
Usage:
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This structure is derived from Extension
Summary
Complex Extension: The Data Enterer Extension represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
Maturity: 2
This structure is derived from Extension
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Extension |
0..* | Extension | Data Enterer Extension | |
  extension |
2..* | Extension | Extension | |
  Slices for extension |
Content/Rules for all slices | |||
   extension:type |
1..* | Extension | Meaning and purpose of participation, in creation of the clinical document. The list includes: data entry person, informant, primary information recipient, and tracker. Other types are allowed. | |
  extension |
0..0 | |||
| url |
1..1 | uri | "type" | |
 Slices for value[x] |
1..1 | CodeableConcept | Value of extension Slice: Unordered, Open by type:$this | |
| value[x]:valueCodeableConcept |
1..1 | CodeableConcept | Value of extension 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://terminology.hl7.org/CodeSystem/v3-ParticipationType | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: ENT | |
 display |
1..1 | string | Representation defined by the system Fixed Value: data entry person | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |
| extension |
0..0 | |||
| url |
1..1 | uri | "function" | |
  value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:time |
0..1 | Extension | Time period of participation | |
| extension |
0..0 | |||
| url |
1..1 | uri | "time" | |
| value[x] |
1..1 | Period | Value of extension | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:party |
S | 1..1 | Extension | participant |
| extension |
0..0 | |||
| url |
1..1 | uri | "party" | |
 value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension" | |
| value[x] |
0..0 | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Extension |
0..* | Extension | Data Enterer Extension | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url | |
 extension:type |
1..* | Extension | Meaning and purpose of participation, in creation of the clinical document. The list includes: data entry person, informant, primary information recipient, and tracker. Other types are allowed. | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "type" | |
| Slices for value[x] |
1..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |
| value[x]:valueCodeableConcept |
1..1 | CodeableConcept | Value of extension 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://terminology.hl7.org/CodeSystem/v3-ParticipationType | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: ENT | |
| display |
1..1 | string | Representation defined by the system Fixed Value: data entry person | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "function" | |
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |
| extension:time |
0..1 | Extension | Time period of participation | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "time" | |
| value[x] |
1..1 | Period | Value of extension | |
| extension:party |
S | 1..1 | Extension | participant |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "party" | |
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension" | |
| Documentation for this format | ||||
This structure is derived from Extension
Summary
Complex Extension: The Data Enterer Extension represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
Maturity: 2
Differential View
This structure is derived from Extension
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Extension |
0..* | Extension | Data Enterer Extension | |
| extension |
2..* | Extension | Extension | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:type |
1..* | Extension | Meaning and purpose of participation, in creation of the clinical document. The list includes: data entry person, informant, primary information recipient, and tracker. Other types are allowed. | |
| extension |
0..0 | |||
| url |
1..1 | uri | "type" | |
| Slices for value[x] |
1..1 | CodeableConcept | Value of extension Slice: Unordered, Open by type:$this | |
| value[x]:valueCodeableConcept |
1..1 | CodeableConcept | Value of extension 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://terminology.hl7.org/CodeSystem/v3-ParticipationType | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: ENT | |
| display |
1..1 | string | Representation defined by the system Fixed Value: data entry person | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |
| extension |
0..0 | |||
| url |
1..1 | uri | "function" | |
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:time |
0..1 | Extension | Time period of participation | |
| extension |
0..0 | |||
| url |
1..1 | uri | "time" | |
| value[x] |
1..1 | Period | Value of extension | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:party |
S | 1..1 | Extension | participant |
| extension |
0..0 | |||
| url |
1..1 | uri | "party" | |
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension" | |
| value[x] |
0..0 | |||
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Extension |
0..* | Extension | Data Enterer Extension | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:type |
1..* | Extension | Meaning and purpose of participation, in creation of the clinical document. The list includes: data entry person, informant, primary information recipient, and tracker. Other types are allowed. | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "type" | |
| Slices for value[x] |
1..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |
| value[x]:valueCodeableConcept |
1..1 | CodeableConcept | Value of extension 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://terminology.hl7.org/CodeSystem/v3-ParticipationType | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: ENT | |
| display |
1..1 | string | Representation defined by the system Fixed Value: data entry person | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "function" | |
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |
| extension:time |
0..1 | Extension | Time period of participation | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "time" | |
| value[x] |
1..1 | Period | Value of extension | |
| extension:party |
S | 1..1 | Extension | participant |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..0 | |||
| url |
1..1 | uri | "party" | |
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension" | |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet | URI |
| Extension.extension:function.value[x] | extensible | ParticipationFunctionhttp://terminology.hl7.org/ValueSet/v3-ParticipationFunction |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
IG © 2024+ HL7 International / Structured Documents. Package hl7.fhir.uv.fhir-clinical-document#1.0.0-ballot based on FHIR 4.0.1. Generated 2024-08-07
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