Health Care Surveys Reporting, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-health-care-surveys-reporting-ig/ and changes regularly. See the Directory of published versions
| Page standards status: Trial-use | Maturity Level: 3 |
Definitions for the hcs-composition resource profile
Guidance on how to interpret the contents of this table can be foundhere
| 0. Composition | |
| Definition | The Health Care Surveys Composition profile establishes the core elements, extensions, vocabularies and value sets for representing heath care surveys. A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). |
| Short | Health Care Surveys CompositionA set of resources composed into a single coherent clinical statement with clinical attestation |
| Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. |
| Control | 0..* |
| Is Modifier | false |
| Summary | false |
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
| 2. Composition.implicitRules | |
| Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
| Short | A set of rules under which this content was created |
| Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
| Control | 0..1 |
| Type | uri |
| Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Summary | true |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 4. Composition.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
| Summary | false |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 6. Composition.identifier | |
| Definition | Health Care Surveys Composition identifier. This is equivalent to ClinicalDocument.setId in CDA. The identifier of the containing Bundle is equivalent to ClinicalDocument.id in CDA. A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. |
| Short | Health Care Surveys Composition identifierVersion-independent identifier for the Composition |
| Comments | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 10..1 |
| Type | Identifier |
| Is Modifier | false |
| Must Support | true |
| Summary | true |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 8. Composition.status | |
| Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. |
| Short | preliminary | final | amended | entered-in-error |
| Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
| Control | 1..1 |
| Binding | The codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)The workflow/clinical status of the composition. |
| Type | code |
| Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Must Support | true |
| Summary | true |
| Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. |
| Fixed Value | final |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 10. Composition.type | |
| Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. |
| Short | National Health Care Surveys reportKind of composition (LOINC if possible) |
| Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
| Control | 1..1 |
| Binding | The codes SHOULD be taken from FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1 (preferred to http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1)Type of a composition. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | true |
| Requirements | Key metadata element describing the composition, used in searching/filtering. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 12. Composition.subject | |
| Definition | This Patient profile represents the subject of the healthcare survey report. Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). |
| Short | Patient who is the subject of the report.Who and/or what the composition is about |
| Comments | For clinical documents, this is usually the patient. |
| Control | 10..1 |
| Type | Reference(US Core Patient Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | true |
| Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 14. Composition.encounter | |
| Definition | This Encounter profile represents the encounter related to the healthcare survey report. Describes the clinical encounter or type of care this documentation is associated with. |
| Short | Encounter related to the public health eventContext of the Composition |
| Control | 10..1 |
| Type | Reference(US Core Encounter Profile, Encounter) |
| Is Modifier | false |
| Must Support | true |
| Summary | true |
| Requirements | Provides context for the composition and supports searching. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 16. Composition.date | |
| Definition | The composition editing time, when the composition was last logically changed by the author. |
| Short | Composition editing time |
| Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
| Control | 1..1 |
| Type | dateTime |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Must Support | true |
| Summary | true |
| Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 18. Composition.author | |
| Definition | It is possible to have multiple authors - especially in the case where the default author is the organization. Author information can contain the "eCR Now FHIR App-Health Care Surveys" as a Device Author. Identifies who is responsible for the information in the composition, not necessarily who typed it in. |
| Short | The author(s) of the documentWho and/or what authored the composition |
| Control | 1..* |
| Type | Reference(US Core PractitionerRole Profile, US Core Practitioner Profile, US Core Organization Profile, Device, Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) |
| Is Modifier | false |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| Summary | true |
| Requirements | Identifies who is responsible for the content. |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 20. Composition.title | |
| Definition | Official human-readable label for the composition. |
| Short | Human Readable name/title |
| Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
| Control | 1..1 |
| Type | string |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| Must Support | true |
| Summary | true |
| Fixed Value | National Health Care Surveys report |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 22. Composition.section | |
| Definition | The root of the sections that make up the composition. |
| Short | Composition is broken into sections |
| Control | 30..* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| Slicing | This element introduces a set of slices on Composition.section. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 24. Composition.section.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 26. Composition.section:reasonForVisitSection | |
| Slice Name | reasonForVisitSection |
| Definition | This section records the reason for the patient's visit (the provider’s description of the reason for visit). The root of the sections that make up the composition. |
| Short | Reason for Visit SectionComposition is broken into sections |
| Control | 10..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 28. Composition.section:reasonForVisitSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 30. Composition.section:reasonForVisitSection.code | |
| Definition | Reason for Visit code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Reason for Visit codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 32. Composition.section:reasonForVisitSection.text | |
| Definition | Reason for Visit narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Reason for Visit narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 34. Composition.section:problemSection | |
| Slice Name | problemSection |
| Definition | This section lists and describes all the patient's current problems on the maintained problem list. The root of the sections that make up the composition. |
| Short | Problem Section (USCDI Data Class: Problems, Encounter)Composition is broken into sections |
| Control | 10..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 36. Composition.section:problemSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 38. Composition.section:problemSection.code | |
| Definition | Problem Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Problem Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 40. Composition.section:problemSection.text | |
| Definition | Problem Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Problem Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 42. Composition.section:problemSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 44. Composition.section:problemSection.entry:problemsHealthConcerns | |
| Slice Name | problemsHealthConcerns |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Problems Health Concerns Entries (USCDI Data Elements: Date of Resolution, Date of Diagnosis, SDOH Problems/Health Concerns, Health Concerns, Disability Status, Functional Status, Mental/Cognitive Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Condition Problems and Health Concerns Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 46. Composition.section:problemSection.entry:encounterDiagnosis | |
| Slice Name | encounterDiagnosis |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Encounter Diagnosis Entries (USCDI Data Elements: Encounter Diagnosis)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Condition Encounter Diagnosis Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 48. Composition.section:allergiesSection | |
| Slice Name | allergiesSection |
| Definition | This section lists and describes all the patient's current allergies on the maintained allergy list. The root of the sections that make up the composition. |
| Short | Allergies Section (USCDI Data Class: Allergies and Intolerances)Composition is broken into sections |
| Control | 10..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 50. Composition.section:allergiesSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 52. Composition.section:allergiesSection.code | |
| Definition | Allergies Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Allergies Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 54. Composition.section:allergiesSection.text | |
| Definition | Allergies Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Allergies Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 56. Composition.section:allergiesSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | AllergyIntolerance Entries (USCDI Data Elements: Substance (Medication), Substance (Drug Class), Reaction)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core AllergyIntolerance Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 58. Composition.section:assessmentAndPlanOfTreatmentSection | |
| Slice Name | assessmentAndPlanOfTreatmentSection |
| Definition | Health professional’s conclusions and working assumptions that will guide treatment of the patient. The root of the sections that make up the composition. |
| Short | Assessment Section (USCDI Data Class: Assessment and Plan of Treatment, Health Status/Assessments)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 60. Composition.section:assessmentAndPlanOfTreatmentSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 62. Composition.section:assessmentAndPlanOfTreatmentSection.code | |
| Definition | Assessment and Plan of Treatment Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Assessment and Plan of Treatment Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 64. Composition.section:assessmentAndPlanOfTreatmentSection.text | |
| Definition | Evaluation + Plan note A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Evaluation + Plan noteText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 66. Composition.section:assessmentAndPlanOfTreatmentSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 68. Composition.section:assessmentAndPlanOfTreatmentSection.entry:screeningAssessment | |
| Slice Name | screeningAssessment |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Assessment Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Observation Screening Assessment Profile, US Core Simple Observation Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 70. Composition.section:assessmentAndPlanOfTreatmentSection.entry:questionnaireResponse | |
| Slice Name | questionnaireResponse |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | QuestionnaireResponse Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core QuestionnaireResponse Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 72. Composition.section:assessmentAndPlanOfTreatmentSection.entry:carePlan | |
| Slice Name | carePlan |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | CarePlan Entries (USCDI Data Elements: Assessment and Plan of Treatment)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core CarePlan Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 74. Composition.section:careTeamSection | |
| Slice Name | careTeamSection |
| Definition | This section lists and describes all the patient's current care team members. The root of the sections that make up the composition. |
| Short | Care Team Section (USCDI Data Class: Care Team Members)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 76. Composition.section:careTeamSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 78. Composition.section:careTeamSection.code | |
| Definition | Care Team Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Care Team Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 80. Composition.section:careTeamSection.text | |
| Definition | Care Team Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Care Team Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 82. Composition.section:careTeamSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Care Team Entries (USCDI Data Elements: Care Team Members - Name, Identifier, Location, Telecom, Role)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core CareTeam Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 84. Composition.section:coverageSection | |
| Slice Name | coverageSection |
| Definition | This section lists the patient's coverage. The root of the sections that make up the composition. |
| Short | Coverage Section (USCDI Data Class: Health Insurance Information)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 86. Composition.section:coverageSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 88. Composition.section:coverageSection.code | |
| Definition | Coverage Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Coverage Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 90. Composition.section:coverageSection.text | |
| Definition | Coverage Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Coverage Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 92. Composition.section:coverageSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Coverage Entries (USCDI Data Elements: Coverage Status, Coverage Type, Relationship to Subscriber, Member Identifier, Subscriber Identifier, Group Number, Payer Identifier)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Coverage Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 94. Composition.section:goalsSection | |
| Slice Name | goalsSection |
| Definition | This section lists and describes the patient's goals. The root of the sections that make up the composition. |
| Short | Goals Section (USCDI Data Class: Goals)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 96. Composition.section:goalsSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 98. Composition.section:goalsSection.code | |
| Definition | Goals Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Goals Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 100. Composition.section:goalsSection.text | |
| Definition | Goals Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Goals Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 102. Composition.section:goalsSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Goal Entries (USCDI Data Elements: Patient Goals, SDOH Goals)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Goal Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 104. Composition.section:immunizationsSection | |
| Slice Name | immunizationsSection |
| Definition | The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized. The root of the sections that make up the composition. |
| Short | Immunizations Section (USCDI Data Class: Immunization)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 106. Composition.section:immunizationsSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 108. Composition.section:immunizationsSection.code | |
| Definition | Immunizations code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Immunizations codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 110. Composition.section:immunizationsSection.text | |
| Definition | Immunizations narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Immunizations narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 112. Composition.section:immunizationsSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Immunization Entries (USCDI Data Elements: Immunizations)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Immunization Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 114. Composition.section:medicalEquipmentSection | |
| Slice Name | medicalEquipmentSection |
| Definition | This section lists and describes all the patient's current implanted devices. The root of the sections that make up the composition. |
| Short | Medical Equipment Section (USCDI Data Class: Unique Device Identifier(s) for a patient's implantable device(s))Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 116. Composition.section:medicalEquipmentSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 118. Composition.section:medicalEquipmentSection.code | |
| Definition | Medical Equipment Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Medical Equipment Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 120. Composition.section:medicalEquipmentSection.text | |
| Definition | Medical Equipment Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Medical Equipment Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 122. Composition.section:medicalEquipmentSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Implantable Device Entries (USCDI Data Elements: Unique Device Identifier(s) for a patient's implantable device(s))A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Implantable Device Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 124. Composition.section:medicationsSection | |
| Slice Name | medicationsSection |
| Definition | The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. The root of the sections that make up the composition. |
| Short | Medications Section (USCDI Data Class: Medications)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 126. Composition.section:medicationsSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 128. Composition.section:medicationsSection.code | |
| Definition | Medications Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Medications Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 130. Composition.section:medicationsSection.text | |
| Definition | Medications Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Medications Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 132. Composition.section:medicationsSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 134. Composition.section:medicationsSection.entry:medicationAdministration | |
| Slice Name | medicationAdministration |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | MedicationAdministration Entries (USCDI Data Elements: Medications, Dose)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Health Care Surveys Medication Administration, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 136. Composition.section:medicationsSection.entry:medicationRequest | |
| Slice Name | medicationRequest |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | MedicationRequest Entries (USCDI Data Elements: Medications, Dose, Dose Unit of Measure, Indication)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core MedicationRequest Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 138. Composition.section:medicationsSection.entry:medicationDispense | |
| Slice Name | medicationDispense |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | MedicationDispense Entries (USCDI Data Elements: Medications, Fill Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core MedicationDispense Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 140. Composition.section:medicationsSection.entry:medication | |
| Slice Name | medication |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Medication Entries (USCDI Data Elements: Medications)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Medication Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 142. Composition.section:clinicalNotesSection | |
| Slice Name | clinicalNotesSection |
| Definition | The Clinical Notes Section contains clinical notes and diagnostic reports. The root of the sections that make up the composition. |
| Short | Clinical Notes SectionComposition is broken into sections |
| Control | 0..* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 144. Composition.section:clinicalNotesSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 146. Composition.section:clinicalNotesSection.code | |
| Definition | Clinical Notes Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Clinical Notes Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 148. Composition.section:clinicalNotesSection.text | |
| Definition | Clinical Notes Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Clinical Notes Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 150. Composition.section:clinicalNotesSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 152. Composition.section:clinicalNotesSection.entry:documentReference | |
| Slice Name | documentReference |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Document Reference Entries (USCDI Data Elements: Consultation Note, Discharge Summary Note, History & Physical, Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note, Progress Note)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core DocumentReference Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 154. Composition.section:clinicalNotesSection.entry:diagnosticReport | |
| Slice Name | diagnosticReport |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Diagnostic Report Entries (USCDI Data Elements: Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core DiagnosticReport Profile for Report and Note Exchange, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 156. Composition.section:pregnancySection | |
| Slice Name | pregnancySection |
| Definition | This section contains pregnancy data The root of the sections that make up the composition. |
| Short | Pregnancy Section (USCDI Data Class: Health Status/Assessments - Pregnancy Status)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 158. Composition.section:pregnancySection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 160. Composition.section:pregnancySection.code | |
| Definition | Pregnancy Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Pregnancy Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 162. Composition.section:pregnancySection.text | |
| Definition | Pregnancy Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Pregnancy Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 164. Composition.section:pregnancySection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 166. Composition.section:pregnancySection.entry:pregnancyStatusObservation | |
| Slice Name | pregnancyStatusObservation |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pregnancy Status Entries (USCDI Data Elements: Pregnancy Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Observation Pregnancy Status Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 168. Composition.section:pregnancySection.entry:pregnancyIntent | |
| Slice Name | pregnancyIntent |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pregnancy Intent Entries (USCDI Data Elements: Pregnancy Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Observation Pregnancy Intent Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 170. Composition.section:proceduresSection | |
| Slice Name | proceduresSection |
| Definition | This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The root of the sections that make up the composition. |
| Short | Procedures Section (USCDI Data Class: Procedures)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 172. Composition.section:proceduresSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 174. Composition.section:proceduresSection.code | |
| Definition | Procedures Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Procedures Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 176. Composition.section:proceduresSection.text | |
| Definition | Procedures Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Procedures Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 178. Composition.section:proceduresSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 180. Composition.section:proceduresSection.entry:procedure | |
| Slice Name | procedure |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Procedure Entries (USCDI Data Elements: Procedure, SDOH Interventions)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Procedure Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 182. Composition.section:proceduresSection.entry:procedureOrder | |
| Slice Name | procedureOrder |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Procedure Order Entries (USCDI Data Elements: Reason for Referral, SDOH Interventions)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core ServiceRequest Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 184. Composition.section:resultsSection | |
| Slice Name | resultsSection |
| Definition | The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. The root of the sections that make up the composition. |
| Short | Results Section (USCDI Data Class: Laboratory, Clinical Tests)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 186. Composition.section:resultsSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 188. Composition.section:resultsSection.code | |
| Definition | Results Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Results Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 190. Composition.section:resultsSection.text | |
| Definition | Results Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Results Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 192. Composition.section:resultsSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 194. Composition.section:resultsSection.entry:result | |
| Slice Name | result |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Laboratory Result Observation Profile, US Core Observation Clinical Result Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 196. Composition.section:resultsSection.entry:diagnosticReport | |
| Slice Name | diagnosticReport |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Diagnostic Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting, US Core DiagnosticReport Profile for Report and Note Exchange, Resource) |
| Is Modifier | false |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 198. Composition.section:socialHistorySection | |
| Slice Name | socialHistorySection |
| Definition | This section contains social history data that influence a patient’s physical, psychological or emotional health. The root of the sections that make up the composition. |
| Short | Social History Section (USCDI Data Class: Health Status/Assessments - Smoking Status, Patient Demographics/Information - Occupation, Occupation Industry)Composition is broken into sections |
| Control | 0..1* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 200. Composition.section:socialHistorySection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 202. Composition.section:socialHistorySection.code | |
| Definition | Social History Section code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Social History Section codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 204. Composition.section:socialHistorySection.text | |
| Definition | Social History Section narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Social History Section narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 206. Composition.section:socialHistorySection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 208. Composition.section:socialHistorySection.entry:smokingStatus | |
| Slice Name | smokingStatus |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Smoking Status Entries (USCDI Data Elements: Smoking Status)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Smoking Status Observation Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 210. Composition.section:socialHistorySection.entry:occupation | |
| Slice Name | occupation |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Occupation Entries (USCDI Data Elements: Occupation, Occupation Industry)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Observation Occupation Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 212. Composition.section:vitalSignsSection | |
| Slice Name | vitalSignsSection |
| Definition | The Vital Signs Section contains relevant vital signs for the report. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. The root of the sections that make up the composition. |
| Short | Vital Signs Section (USCDI Data Class: Vital Signs)Composition is broken into sections |
| Control | 0..* |
| Type | BackboneElement |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
| 214. Composition.section:vitalSignsSection.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
| 216. Composition.section:vitalSignsSection.code | |
| Definition | Vital Signs code A code identifying the kind of content contained within the section. This must be consistent with the section title. |
| Short | Vital Signs codeClassification of section (recommended) |
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
| Control | 10..1 |
| Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. |
| Type | CodeableConcept |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Requirements | Provides computable standardized labels to topics within the document. |
| Pattern Value | { |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 218. Composition.section:vitalSignsSection.text | |
| Definition | Vital Signs narrative A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
| Short | Vital Signs narrativeText summary of the section, for human interpretation |
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
| Control | 10..1 This element is affected by the following invariants: cmp-1 |
| Type | Narrative |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 220. Composition.section:vitalSignsSection.entry | |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 222. Composition.section:vitalSignsSection.entry:bloodPressure | |
| Slice Name | bloodPressure |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Blood Pressure Entries (USCDI Data Elements: Systolic Blood Pressure, Diastolic Blood Pressure)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Blood Pressure Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 224. Composition.section:vitalSignsSection.entry:bodyWeight | |
| Slice Name | bodyWeight |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Body Weight Entries (USCDI Data Elements: Body Weight)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Body Weight Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 226. Composition.section:vitalSignsSection.entry:bodyHeight | |
| Slice Name | bodyHeight |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Body Height Entries (USCDI Data Elements: Body Height)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Body Height Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 228. Composition.section:vitalSignsSection.entry:heartRate | |
| Slice Name | heartRate |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Heart Rate Entries (USCDI Data Elements: Heart Rate)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Heart Rate Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 230. Composition.section:vitalSignsSection.entry:pulseOximetry | |
| Slice Name | pulseOximetry |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pulse Oximetry Entries (USCDI Data Elements: Pulse Oximetry)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Pulse Oximetry Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 232. Composition.section:vitalSignsSection.entry:pediatricWeightForHeight | |
| Slice Name | pediatricWeightForHeight |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pediatric Weight For Height Entries (USCDI Data Elements: Pediatric Weight For Length Percentile (Birth to 36 months))A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Pediatric Weight for Height Observation Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 234. Composition.section:vitalSignsSection.entry:pediatricHeadOccipitalFrontalCircumference | |
| Slice Name | pediatricHeadOccipitalFrontalCircumference |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pediatric Head Occipital Frontal Circumference Percentile Entries (USCDI Data Elements: Occipital Frontal Head Circumference Percentile (Birth to 36 months))A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Pediatric Head Occipital Frontal Circumference Percentile Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 236. Composition.section:vitalSignsSection.entry:pediatricBMIForAge | |
| Slice Name | pediatricBMIForAge |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Pediatric BMI For Age Entries (USCDI Data Elements: BMI Percentile (2-20 years old))A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Pediatric BMI for Age Observation Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 238. Composition.section:vitalSignsSection.entry:bodyTemperature | |
| Slice Name | bodyTemperature |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Body Temperature Entries (USCDI Data Elements: Body Temperature)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Body Temperature Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 240. Composition.section:vitalSignsSection.entry:respiratoryRate | |
| Slice Name | respiratoryRate |
| Definition | A reference to the actual resource from which the narrative in the section is derived. |
| Short | Respiratory Rate Entries (USCDI Data Elements: Respiratory Rate)A reference to data that supports this section |
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
| Control | 0..* This element is affected by the following invariants: cmp-2 |
| Type | Reference(US Core Respiratory Rate Profile, Resource) |
| Is Modifier | false |
| Must Support | true |
| Summary | false |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be foundhere
| 0. Composition | |
| Definition | The Health Care Surveys Composition profile establishes the core elements, extensions, vocabularies and value sets for representing heath care surveys. |
| Short | Health Care Surveys Composition |
| 2. Composition.identifier | |
| Definition | Health Care Surveys Composition identifier. This is equivalent to ClinicalDocument.setId in CDA. The identifier of the containing Bundle is equivalent to ClinicalDocument.id in CDA. |
| Short | Health Care Surveys Composition identifier |
| Note | This is a business identifier, not a resource identifier (see discussion) |
| Control | 1..? |
| Must Support | true |
| 4. Composition.status | |
| Must Support | true |
| Fixed Value | final |
| 6. Composition.type | |
| Short | National Health Care Surveys report |
| Must Support | true |
| Pattern Value | { |
| 8. Composition.subject | |
| Definition | This Patient profile represents the subject of the healthcare survey report. |
| Short | Patient who is the subject of the report. |
| Control | 1..? |
| Type | Reference(US Core Patient Profile) |
| Must Support | true |
| 10. Composition.encounter | |
| Definition | This Encounter profile represents the encounter related to the healthcare survey report. |
| Short | Encounter related to the public health event |
| Control | 1..? |
| Type | Reference(US Core Encounter Profile) |
| Must Support | true |
| 12. Composition.date | |
| Must Support | true |
| 14. Composition.author | |
| Definition | It is possible to have multiple authors - especially in the case where the default author is the organization. Author information can contain the "eCR Now FHIR App-Health Care Surveys" as a Device Author. |
| Short | The author(s) of the document |
| Type | Reference(US Core PractitionerRole Profile, US Core Practitioner Profile, US Core Organization Profile, Device) |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| 16. Composition.title | |
| Must Support | true |
| Fixed Value | National Health Care Surveys report |
| 18. Composition.section | |
| Control | 3..? |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 20. Composition.section:reasonForVisitSection | |
| Slice Name | reasonForVisitSection |
| Definition | This section records the reason for the patient's visit (the provider’s description of the reason for visit). |
| Short | Reason for Visit Section |
| Control | 1..1 |
| Must Support | true |
| 22. Composition.section:reasonForVisitSection.code | |
| Definition | Reason for Visit code |
| Short | Reason for Visit code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 24. Composition.section:reasonForVisitSection.text | |
| Definition | Reason for Visit narrative |
| Short | Reason for Visit narrative |
| Control | 1..? |
| Must Support | true |
| 26. Composition.section:problemSection | |
| Slice Name | problemSection |
| Definition | This section lists and describes all the patient's current problems on the maintained problem list. |
| Short | Problem Section (USCDI Data Class: Problems, Encounter) |
| Control | 1..1 |
| Must Support | true |
| 28. Composition.section:problemSection.code | |
| Definition | Problem Section code |
| Short | Problem Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 30. Composition.section:problemSection.text | |
| Definition | Problem Section narrative |
| Short | Problem Section narrative |
| Control | 1..? |
| Must Support | true |
| 32. Composition.section:problemSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 34. Composition.section:problemSection.entry:problemsHealthConcerns | |
| Slice Name | problemsHealthConcerns |
| Short | Problems Health Concerns Entries (USCDI Data Elements: Date of Resolution, Date of Diagnosis, SDOH Problems/Health Concerns, Health Concerns, Disability Status, Functional Status, Mental/Cognitive Status) |
| Control | 0..* |
| Type | Reference(US Core Condition Problems and Health Concerns Profile) |
| Must Support | true |
| 36. Composition.section:problemSection.entry:encounterDiagnosis | |
| Slice Name | encounterDiagnosis |
| Short | Encounter Diagnosis Entries (USCDI Data Elements: Encounter Diagnosis) |
| Control | 0..* |
| Type | Reference(US Core Condition Encounter Diagnosis Profile) |
| Must Support | true |
| 38. Composition.section:allergiesSection | |
| Slice Name | allergiesSection |
| Definition | This section lists and describes all the patient's current allergies on the maintained allergy list. |
| Short | Allergies Section (USCDI Data Class: Allergies and Intolerances) |
| Control | 1..1 |
| Must Support | true |
| 40. Composition.section:allergiesSection.code | |
| Definition | Allergies Section code |
| Short | Allergies Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 42. Composition.section:allergiesSection.text | |
| Definition | Allergies Section narrative |
| Short | Allergies Section narrative |
| Control | 1..? |
| Must Support | true |
| 44. Composition.section:allergiesSection.entry | |
| Short | AllergyIntolerance Entries (USCDI Data Elements: Substance (Medication), Substance (Drug Class), Reaction) |
| Type | Reference(US Core AllergyIntolerance Profile) |
| Must Support | true |
| 46. Composition.section:assessmentAndPlanOfTreatmentSection | |
| Slice Name | assessmentAndPlanOfTreatmentSection |
| Definition | Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
| Short | Assessment Section (USCDI Data Class: Assessment and Plan of Treatment, Health Status/Assessments) |
| Control | 0..1 |
| Must Support | true |
| 48. Composition.section:assessmentAndPlanOfTreatmentSection.code | |
| Definition | Assessment and Plan of Treatment Section code |
| Short | Assessment and Plan of Treatment Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 50. Composition.section:assessmentAndPlanOfTreatmentSection.text | |
| Definition | Evaluation + Plan note |
| Short | Evaluation + Plan note |
| Control | 1..? |
| Must Support | true |
| 52. Composition.section:assessmentAndPlanOfTreatmentSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 54. Composition.section:assessmentAndPlanOfTreatmentSection.entry:screeningAssessment | |
| Slice Name | screeningAssessment |
| Short | Assessment Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status) |
| Control | 0..* |
| Type | Reference(US Core Observation Screening Assessment Profile, US Core Simple Observation Profile) |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| 56. Composition.section:assessmentAndPlanOfTreatmentSection.entry:questionnaireResponse | |
| Slice Name | questionnaireResponse |
| Short | QuestionnaireResponse Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status) |
| Control | 0..* |
| Type | Reference(US Core QuestionnaireResponse Profile) |
| Must Support | true |
| 58. Composition.section:assessmentAndPlanOfTreatmentSection.entry:carePlan | |
| Slice Name | carePlan |
| Short | CarePlan Entries (USCDI Data Elements: Assessment and Plan of Treatment) |
| Control | 0..* |
| Type | Reference(US Core CarePlan Profile) |
| Must Support | true |
| 60. Composition.section:careTeamSection | |
| Slice Name | careTeamSection |
| Definition | This section lists and describes all the patient's current care team members. |
| Short | Care Team Section (USCDI Data Class: Care Team Members) |
| Control | 0..1 |
| Must Support | true |
| 62. Composition.section:careTeamSection.code | |
| Definition | Care Team Section code |
| Short | Care Team Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 64. Composition.section:careTeamSection.text | |
| Definition | Care Team Section narrative |
| Short | Care Team Section narrative |
| Control | 1..? |
| Must Support | true |
| 66. Composition.section:careTeamSection.entry | |
| Short | Care Team Entries (USCDI Data Elements: Care Team Members - Name, Identifier, Location, Telecom, Role) |
| Type | Reference(US Core CareTeam Profile) |
| Must Support | true |
| 68. Composition.section:coverageSection | |
| Slice Name | coverageSection |
| Definition | This section lists the patient's coverage. |
| Short | Coverage Section (USCDI Data Class: Health Insurance Information) |
| Control | 0..1 |
| Must Support | true |
| 70. Composition.section:coverageSection.code | |
| Definition | Coverage Section code |
| Short | Coverage Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 72. Composition.section:coverageSection.text | |
| Definition | Coverage Section narrative |
| Short | Coverage Section narrative |
| Control | 1..? |
| Must Support | true |
| 74. Composition.section:coverageSection.entry | |
| Short | Coverage Entries (USCDI Data Elements: Coverage Status, Coverage Type, Relationship to Subscriber, Member Identifier, Subscriber Identifier, Group Number, Payer Identifier) |
| Type | Reference(US Core Coverage Profile) |
| Must Support | true |
| 76. Composition.section:goalsSection | |
| Slice Name | goalsSection |
| Definition | This section lists and describes the patient's goals. |
| Short | Goals Section (USCDI Data Class: Goals) |
| Control | 0..1 |
| Must Support | true |
| 78. Composition.section:goalsSection.code | |
| Definition | Goals Section code |
| Short | Goals Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 80. Composition.section:goalsSection.text | |
| Definition | Goals Section narrative |
| Short | Goals Section narrative |
| Control | 1..? |
| Must Support | true |
| 82. Composition.section:goalsSection.entry | |
| Short | Goal Entries (USCDI Data Elements: Patient Goals, SDOH Goals) |
| Type | Reference(US Core Goal Profile) |
| Must Support | true |
| 84. Composition.section:immunizationsSection | |
| Slice Name | immunizationsSection |
| Definition | The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized. |
| Short | Immunizations Section (USCDI Data Class: Immunization) |
| Control | 0..1 |
| Must Support | true |
| 86. Composition.section:immunizationsSection.code | |
| Definition | Immunizations code |
| Short | Immunizations code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 88. Composition.section:immunizationsSection.text | |
| Definition | Immunizations narrative |
| Short | Immunizations narrative |
| Control | 1..? |
| Must Support | true |
| 90. Composition.section:immunizationsSection.entry | |
| Short | Immunization Entries (USCDI Data Elements: Immunizations) |
| Type | Reference(US Core Immunization Profile) |
| Must Support | true |
| 92. Composition.section:medicalEquipmentSection | |
| Slice Name | medicalEquipmentSection |
| Definition | This section lists and describes all the patient's current implanted devices. |
| Short | Medical Equipment Section (USCDI Data Class: Unique Device Identifier(s) for a patient's implantable device(s)) |
| Control | 0..1 |
| Must Support | true |
| 94. Composition.section:medicalEquipmentSection.code | |
| Definition | Medical Equipment Section code |
| Short | Medical Equipment Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 96. Composition.section:medicalEquipmentSection.text | |
| Definition | Medical Equipment Section narrative |
| Short | Medical Equipment Section narrative |
| Control | 1..? |
| Must Support | true |
| 98. Composition.section:medicalEquipmentSection.entry | |
| Short | Implantable Device Entries (USCDI Data Elements: Unique Device Identifier(s) for a patient's implantable device(s)) |
| Type | Reference(US Core Implantable Device Profile) |
| Must Support | true |
| 100. Composition.section:medicationsSection | |
| Slice Name | medicationsSection |
| Definition | The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. |
| Short | Medications Section (USCDI Data Class: Medications) |
| Control | 0..1 |
| Must Support | true |
| 102. Composition.section:medicationsSection.code | |
| Definition | Medications Section code |
| Short | Medications Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 104. Composition.section:medicationsSection.text | |
| Definition | Medications Section narrative |
| Short | Medications Section narrative |
| Control | 1..? |
| Must Support | true |
| 106. Composition.section:medicationsSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 108. Composition.section:medicationsSection.entry:medicationAdministration | |
| Slice Name | medicationAdministration |
| Short | MedicationAdministration Entries (USCDI Data Elements: Medications, Dose) |
| Control | 0..* |
| Type | Reference(Health Care Surveys Medication Administration) |
| Must Support | true |
| 110. Composition.section:medicationsSection.entry:medicationRequest | |
| Slice Name | medicationRequest |
| Short | MedicationRequest Entries (USCDI Data Elements: Medications, Dose, Dose Unit of Measure, Indication) |
| Control | 0..* |
| Type | Reference(US Core MedicationRequest Profile) |
| Must Support | true |
| 112. Composition.section:medicationsSection.entry:medicationDispense | |
| Slice Name | medicationDispense |
| Short | MedicationDispense Entries (USCDI Data Elements: Medications, Fill Status) |
| Control | 0..* |
| Type | Reference(US Core MedicationDispense Profile) |
| Must Support | true |
| 114. Composition.section:medicationsSection.entry:medication | |
| Slice Name | medication |
| Short | Medication Entries (USCDI Data Elements: Medications) |
| Control | 0..* |
| Type | Reference(US Core Medication Profile) |
| Must Support | true |
| 116. Composition.section:clinicalNotesSection | |
| Slice Name | clinicalNotesSection |
| Definition | The Clinical Notes Section contains clinical notes and diagnostic reports. |
| Short | Clinical Notes Section |
| Control | 0..* |
| Must Support | true |
| 118. Composition.section:clinicalNotesSection.code | |
| Definition | Clinical Notes Section code |
| Short | Clinical Notes Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 120. Composition.section:clinicalNotesSection.text | |
| Definition | Clinical Notes Section narrative |
| Short | Clinical Notes Section narrative |
| Control | 1..? |
| Must Support | true |
| 122. Composition.section:clinicalNotesSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 124. Composition.section:clinicalNotesSection.entry:documentReference | |
| Slice Name | documentReference |
| Short | Document Reference Entries (USCDI Data Elements: Consultation Note, Discharge Summary Note, History & Physical, Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note, Progress Note) |
| Control | 0..* |
| Type | Reference(US Core DocumentReference Profile) |
| Must Support | true |
| 126. Composition.section:clinicalNotesSection.entry:diagnosticReport | |
| Slice Name | diagnosticReport |
| Short | Diagnostic Report Entries (USCDI Data Elements: Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note) |
| Control | 0..* |
| Type | Reference(US Core DiagnosticReport Profile for Report and Note Exchange) |
| Must Support | true |
| 128. Composition.section:pregnancySection | |
| Slice Name | pregnancySection |
| Definition | This section contains pregnancy data |
| Short | Pregnancy Section (USCDI Data Class: Health Status/Assessments - Pregnancy Status) |
| Control | 0..1 |
| Must Support | true |
| 130. Composition.section:pregnancySection.code | |
| Definition | Pregnancy Section code |
| Short | Pregnancy Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 132. Composition.section:pregnancySection.text | |
| Definition | Pregnancy Section narrative |
| Short | Pregnancy Section narrative |
| Control | 1..? |
| Must Support | true |
| 134. Composition.section:pregnancySection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 136. Composition.section:pregnancySection.entry:pregnancyStatusObservation | |
| Slice Name | pregnancyStatusObservation |
| Short | Pregnancy Status Entries (USCDI Data Elements: Pregnancy Status) |
| Control | 0..* |
| Type | Reference(US Core Observation Pregnancy Status Profile) |
| Must Support | true |
| 138. Composition.section:pregnancySection.entry:pregnancyIntent | |
| Slice Name | pregnancyIntent |
| Short | Pregnancy Intent Entries (USCDI Data Elements: Pregnancy Status) |
| Control | 0..* |
| Type | Reference(US Core Observation Pregnancy Intent Profile) |
| Must Support | true |
| 140. Composition.section:proceduresSection | |
| Slice Name | proceduresSection |
| Definition | This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. |
| Short | Procedures Section (USCDI Data Class: Procedures) |
| Control | 0..1 |
| Must Support | true |
| 142. Composition.section:proceduresSection.code | |
| Definition | Procedures Section code |
| Short | Procedures Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 144. Composition.section:proceduresSection.text | |
| Definition | Procedures Section narrative |
| Short | Procedures Section narrative |
| Control | 1..? |
| Must Support | true |
| 146. Composition.section:proceduresSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 148. Composition.section:proceduresSection.entry:procedure | |
| Slice Name | procedure |
| Short | Procedure Entries (USCDI Data Elements: Procedure, SDOH Interventions) |
| Control | 0..* |
| Type | Reference(US Core Procedure Profile) |
| Must Support | true |
| 150. Composition.section:proceduresSection.entry:procedureOrder | |
| Slice Name | procedureOrder |
| Short | Procedure Order Entries (USCDI Data Elements: Reason for Referral, SDOH Interventions) |
| Control | 0..* |
| Type | Reference(US Core ServiceRequest Profile) |
| Must Support | true |
| 152. Composition.section:resultsSection | |
| Slice Name | resultsSection |
| Definition | The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. |
| Short | Results Section (USCDI Data Class: Laboratory, Clinical Tests) |
| Control | 0..1 |
| Must Support | true |
| 154. Composition.section:resultsSection.code | |
| Definition | Results Section code |
| Short | Results Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 156. Composition.section:resultsSection.text | |
| Definition | Results Section narrative |
| Short | Results Section narrative |
| Control | 1..? |
| Must Support | true |
| 158. Composition.section:resultsSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 160. Composition.section:resultsSection.entry:result | |
| Slice Name | result |
| Short | Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report) |
| Control | 0..* |
| Type | Reference(US Core Laboratory Result Observation Profile, US Core Observation Clinical Result Profile) |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| 162. Composition.section:resultsSection.entry:diagnosticReport | |
| Slice Name | diagnosticReport |
| Short | Diagnostic Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report) |
| Control | 0..* |
| Type | Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting, US Core DiagnosticReport Profile for Report and Note Exchange) |
| Must Support | true |
| Must Support Types | No must-support rules about the choice of types/profiles |
| 164. Composition.section:socialHistorySection | |
| Slice Name | socialHistorySection |
| Definition | This section contains social history data that influence a patient’s physical, psychological or emotional health. |
| Short | Social History Section (USCDI Data Class: Health Status/Assessments - Smoking Status, Patient Demographics/Information - Occupation, Occupation Industry) |
| Control | 0..1 |
| Must Support | true |
| 166. Composition.section:socialHistorySection.code | |
| Definition | Social History Section code |
| Short | Social History Section code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 168. Composition.section:socialHistorySection.text | |
| Definition | Social History Section narrative |
| Short | Social History Section narrative |
| Control | 1..? |
| Must Support | true |
| 170. Composition.section:socialHistorySection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 172. Composition.section:socialHistorySection.entry:smokingStatus | |
| Slice Name | smokingStatus |
| Short | Smoking Status Entries (USCDI Data Elements: Smoking Status) |
| Control | 0..* |
| Type | Reference(US Core Smoking Status Observation Profile) |
| Must Support | true |
| 174. Composition.section:socialHistorySection.entry:occupation | |
| Slice Name | occupation |
| Short | Occupation Entries (USCDI Data Elements: Occupation, Occupation Industry) |
| Control | 0..* |
| Type | Reference(US Core Observation Occupation Profile) |
| Must Support | true |
| 176. Composition.section:vitalSignsSection | |
| Slice Name | vitalSignsSection |
| Definition | The Vital Signs Section contains relevant vital signs for the report. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. |
| Short | Vital Signs Section (USCDI Data Class: Vital Signs) |
| Control | 0..* |
| Must Support | true |
| 178. Composition.section:vitalSignsSection.code | |
| Definition | Vital Signs code |
| Short | Vital Signs code |
| Control | 1..? |
| Must Support | true |
| Pattern Value | { |
| 180. Composition.section:vitalSignsSection.text | |
| Definition | Vital Signs narrative |
| Short | Vital Signs narrative |
| Control | 1..? |
| Must Support | true |
| 182. Composition.section:vitalSignsSection.entry | |
| Must Support | true |
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 184. Composition.section:vitalSignsSection.entry:bloodPressure | |
| Slice Name | bloodPressure |
| Short | Blood Pressure Entries (USCDI Data Elements: Systolic Blood Pressure, Diastolic Blood Pressure) |
| Control | 0..* |
| Type | Reference(US Core Blood Pressure Profile) |
| Must Support | true |
| 186. Composition.section:vitalSignsSection.entry:bodyWeight | |
| Slice Name | bodyWeight |
| Short | Body Weight Entries (USCDI Data Elements: Body Weight) |
| Control | 0..* |
| Type | Reference(US Core Body Weight Profile) |
| Must Support | true |
| 188. Composition.section:vitalSignsSection.entry:bodyHeight | |
| Slice Name | bodyHeight |
| Short | Body Height Entries (USCDI Data Elements: Body Height) |
| Control | 0..* |
| Type | Reference(US Core Body Height Profile) |
| Must Support | true |
| 190. Composition.section:vitalSignsSection.entry:heartRate | |
| Slice Name | heartRate |
| Short | Heart Rate Entries (USCDI Data Elements: Heart Rate) |
| Control | 0..* |
| Type | Reference(US Core Heart Rate Profile) |
| Must Support | true |
| 192. Composition.section:vitalSignsSection.entry:pulseOximetry | |
| Slice Name | pulseOximetry |
| Short | Pulse Oximetry Entries (USCDI Data Elements: Pulse Oximetry) |
| Control | 0..* |
| Type | Reference(US Core Pulse Oximetry Profile) |
| Must Support | true |
| 194. Composition.section:vitalSignsSection.entry:pediatricWeightForHeight | |
| Slice Name | pediatricWeightForHeight |
| Short | Pediatric Weight For Height Entries (USCDI Data Elements: Pediatric Weight For Length Percentile (Birth to 36 months)) |
| Control | 0..* |
| Type | Reference(US Core Pediatric Weight for Height Observation Profile) |
| Must Support | true |
| 196. Composition.section:vitalSignsSection.entry:pediatricHeadOccipitalFrontalCircumference | |
| Slice Name | pediatricHeadOccipitalFrontalCircumference |
| Short | Pediatric Head Occipital Frontal Circumference Percentile Entries (USCDI Data Elements: Occipital Frontal Head Circumference Percentile (Birth to 36 months)) |
| Control | 0..* |
| Type | Reference(US Core Pediatric Head Occipital Frontal Circumference Percentile Profile) |
| Must Support | true |
| 198. Composition.section:vitalSignsSection.entry:pediatricBMIForAge | |
| Slice Name | pediatricBMIForAge |
| Short | Pediatric BMI For Age Entries (USCDI Data Elements: BMI Percentile (2-20 years old)) |
| Control | 0..* |
| Type | Reference(US Core Pediatric BMI for Age Observation Profile) |
| Must Support | true |
| 200. Composition.section:vitalSignsSection.entry:bodyTemperature | |
| Slice Name | bodyTemperature |
| Short | Body Temperature Entries (USCDI Data Elements: Body Temperature) |
| Control | 0..* |
| Type | Reference(US Core Body Temperature Profile) |
| Must Support | true |
| 202. Composition.section:vitalSignsSection.entry:respiratoryRate | |
| Slice Name | respiratoryRate |
| Short | Respiratory Rate Entries (USCDI Data Elements: Respiratory Rate) |
| Control | 0..* |
| Type | Reference(US Core Respiratory Rate Profile) |
| Must Support | true |
Guidance on how to interpret the contents of this table can be foundhere
| 0. Composition | |||||
| Definition | The Health Care Surveys Composition profile establishes the core elements, extensions, vocabularies and value sets for representing heath care surveys. | ||||
| Short | Health Care Surveys Composition | ||||
| Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. | ||||
| Control | 0..* | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty())dom-6: A resource should have narrative for robust management ( text.`div`.exists()) | ||||
| 2. Composition.id | |||||
| Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
| Short | Logical id of this artifact | ||||
| Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
| Control | 0..1 | ||||
| Type | id | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| 4. Composition.meta | |||||
| Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
| Short | Metadata about the resource | ||||
| Control | 0..1 | ||||
| Type | Meta | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 6. Composition.implicitRules | |||||
| Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
| Short | A set of rules under which this content was created | ||||
| Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
| Control | 0..1 | ||||
| Type | uri | ||||
| Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 8. Composition.language | |||||
| Definition | The base language in which the resource is written. | ||||
| Short | Language of the resource content | ||||
| Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages|4.0.1)A human language.
| ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 10. Composition.text | |||||
| Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Short | Text summary of the resource, for human interpretation | ||||
| Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
| Control | 0..1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | narrative, html, xhtml, display | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 12. Composition.contained | |||||
| Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
| Short | Contained, inline Resources | ||||
| Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
| Control | 0..* | ||||
| Type | Resource | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | inline resources, anonymous resources, contained resources | ||||
| 14. Composition.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 16. Composition.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
| Summary | false | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 18. Composition.identifier | |||||
| Definition | Health Care Surveys Composition identifier. This is equivalent to ClinicalDocument.setId in CDA. The identifier of the containing Bundle is equivalent to ClinicalDocument.id in CDA. | ||||
| Short | Health Care Surveys Composition identifier | ||||
| Comments | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. | ||||
| Note | This is a business identifier, not a resource identifier (see discussion) | ||||
| Control | 1..1 | ||||
| Type | Identifier | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 20. Composition.status | |||||
| Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | ||||
| Short | preliminary | final | amended | entered-in-error | ||||
| Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. | ||||
| Control | 1..1 | ||||
| Binding | The codes SHALL be taken from CompositionStatus (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1)The workflow/clinical status of the composition. | ||||
| Type | code | ||||
| Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. | ||||
| Fixed Value | final | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 22. Composition.type | |||||
| Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. | ||||
| Short | National Health Care Surveys report | ||||
| Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. | ||||
| Control | 1..1 | ||||
| Binding | The codes SHOULD be taken from FHIRDocumentTypeCodes (preferred to http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1)Type of a composition. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Requirements | Key metadata element describing the composition, used in searching/filtering. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 24. Composition.category | |||||
| Definition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. | ||||
| Short | Categorization of Composition | ||||
| Comments | This is a metadata field from XDS/MHD. | ||||
| Control | 0..* | ||||
| Binding | For example codes, see DocumentClassValueSet (example to http://hl7.org/fhir/ValueSet/document-classcodes|4.0.1)High-level kind of a clinical document at a macro level. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 26. Composition.subject | |||||
| Definition | This Patient profile represents the subject of the healthcare survey report. | ||||
| Short | Patient who is the subject of the report. | ||||
| Comments | For clinical documents, this is usually the patient. | ||||
| Control | 1..1 | ||||
| Type | Reference(US Core Patient Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 28. Composition.encounter | |||||
| Definition | This Encounter profile represents the encounter related to the healthcare survey report. | ||||
| Short | Encounter related to the public health event | ||||
| Control | 1..1 | ||||
| Type | Reference(US Core Encounter Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Requirements | Provides context for the composition and supports searching. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 30. Composition.date | |||||
| Definition | The composition editing time, when the composition was last logically changed by the author. | ||||
| Short | Composition editing time | ||||
| Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. | ||||
| Control | 1..1 | ||||
| Type | dateTime | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 32. Composition.author | |||||
| Definition | It is possible to have multiple authors - especially in the case where the default author is the organization. Author information can contain the "eCR Now FHIR App-Health Care Surveys" as a Device Author. | ||||
| Short | The author(s) of the document | ||||
| Control | 1..* | ||||
| Type | Reference(US Core PractitionerRole Profile, US Core Practitioner Profile, US Core Organization Profile, Device) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Must Support Types | No must-support rules about the choice of types/profiles | ||||
| Summary | true | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 34. Composition.title | |||||
| Definition | Official human-readable label for the composition. | ||||
| Short | Human Readable name/title | ||||
| Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. | ||||
| Control | 1..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Must Support | true | ||||
| Summary | true | ||||
| Fixed Value | National Health Care Surveys report | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 36. Composition.confidentiality | |||||
| Definition | The code specifying the level of confidentiality of the Composition. | ||||
| Short | As defined by affinity domain | ||||
| Comments | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26) (required to http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26)Codes specifying the level of confidentiality of the composition. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 38. Composition.attester | |||||
| Definition | A participant who has attested to the accuracy of the composition/document. | ||||
| Short | Attests to accuracy of composition | ||||
| Comments | Only list each attester once. | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies responsibility for the accuracy of the composition content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 40. Composition.attester.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 42. Composition.attester.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 44. Composition.attester.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 46. Composition.attester.mode | |||||
| Definition | The type of attestation the authenticator offers. | ||||
| Short | personal | professional | legal | official | ||||
| Control | 1..1 | ||||
| Binding | The codes SHALL be taken from CompositionAttestationMode (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1)The way in which a person authenticated a composition. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Indicates the level of authority of the attestation. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 48. Composition.attester.time | |||||
| Definition | When the composition was attested by the party. | ||||
| Short | When the composition was attested | ||||
| Control | 0..1 | ||||
| Type | dateTime | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 50. Composition.attester.party | |||||
| Definition | Who attested the composition in the specified way. | ||||
| Short | Who attested the composition | ||||
| Control | 0..1 | ||||
| Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 52. Composition.custodian | |||||
| Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | ||||
| Short | Organization which maintains the composition | ||||
| Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. | ||||
| Control | 0..1 | ||||
| Type | Reference(Organization) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Identifies where to go to find the current version, where to report issues, etc. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 54. Composition.relatesTo | |||||
| Definition | Relationships that this composition has with other compositions or documents that already exist. | ||||
| Short | Relationships to other compositions/documents | ||||
| Comments | A document is a version specific composition. | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 56. Composition.relatesTo.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 58. Composition.relatesTo.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 60. Composition.relatesTo.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 62. Composition.relatesTo.code | |||||
| Definition | The type of relationship that this composition has with anther composition or document. | ||||
| Short | replaces | transforms | signs | appends | ||||
| Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. | ||||
| Control | 1..1 | ||||
| Binding | The codes SHALL be taken from DocumentRelationshipType (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)The type of relationship between documents. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 64. Composition.relatesTo.target[x] | |||||
| Definition | The target composition/document of this relationship. | ||||
| Short | Target of the relationship | ||||
| Control | 1..1 | ||||
| Type | Choice of: Identifier, Reference(Composition) | ||||
| [x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 66. Composition.event | |||||
| Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. | ||||
| Short | The clinical service(s) being documented | ||||
| Comments | The event needs to be consistent with the type element, though can provide further information if desired. | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 68. Composition.event.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 70. Composition.event.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 72. Composition.event.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 74. Composition.event.code | |||||
| Definition | This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. | ||||
| Short | Code(s) that apply to the event being documented | ||||
| Comments | An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. | ||||
| Control | 0..* | ||||
| Binding | For example codes, see ActCode (3.0.0) (example to http://terminology.hl7.org/ValueSet/v3-ActCode|3.0.0)This list of codes represents the main clinical acts being documented. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 76. Composition.event.period | |||||
| Definition | The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. | ||||
| Short | The period covered by the documentation | ||||
| Control | 0..1 | ||||
| Type | Period | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 78. Composition.event.detail | |||||
| Definition | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. | ||||
| Short | The event(s) being documented | ||||
| Control | 0..* | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 80. Composition.section | |||||
| Definition | The root of the sections that make up the composition. | ||||
| Short | Composition is broken into sections | ||||
| Control | 3..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 82. Composition.section.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 84. Composition.section.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 86. Composition.section.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 88. Composition.section.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 90. Composition.section.code | |||||
| Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||||
| Short | Classification of section (recommended) | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 0..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 92. Composition.section.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 94. Composition.section.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 96. Composition.section.text | |||||
| Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. | ||||
| Short | Text summary of the section, for human interpretation | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 98. Composition.section.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 100. Composition.section.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 102. Composition.section.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 104. Composition.section.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 106. Composition.section.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 108. Composition.section:reasonForVisitSection | |||||
| Slice Name | reasonForVisitSection | ||||
| Definition | This section records the reason for the patient's visit (the provider’s description of the reason for visit). | ||||
| Short | Reason for Visit Section | ||||
| Control | 1..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 110. Composition.section:reasonForVisitSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 112. Composition.section:reasonForVisitSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 114. Composition.section:reasonForVisitSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 116. Composition.section:reasonForVisitSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 118. Composition.section:reasonForVisitSection.code | |||||
| Definition | Reason for Visit code | ||||
| Short | Reason for Visit code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 120. Composition.section:reasonForVisitSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 122. Composition.section:reasonForVisitSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 124. Composition.section:reasonForVisitSection.text | |||||
| Definition | Reason for Visit narrative | ||||
| Short | Reason for Visit narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 126. Composition.section:reasonForVisitSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 128. Composition.section:reasonForVisitSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 130. Composition.section:reasonForVisitSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 132. Composition.section:reasonForVisitSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 134. Composition.section:reasonForVisitSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 136. Composition.section:problemSection | |||||
| Slice Name | problemSection | ||||
| Definition | This section lists and describes all the patient's current problems on the maintained problem list. | ||||
| Short | Problem Section (USCDI Data Class: Problems, Encounter) | ||||
| Control | 1..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 138. Composition.section:problemSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 140. Composition.section:problemSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 142. Composition.section:problemSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 144. Composition.section:problemSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 146. Composition.section:problemSection.code | |||||
| Definition | Problem Section code | ||||
| Short | Problem Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 148. Composition.section:problemSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 150. Composition.section:problemSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 152. Composition.section:problemSection.text | |||||
| Definition | Problem Section narrative | ||||
| Short | Problem Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 154. Composition.section:problemSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 156. Composition.section:problemSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 158. Composition.section:problemSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 160. Composition.section:problemSection.entry:problemsHealthConcerns | |||||
| Slice Name | problemsHealthConcerns | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Problems Health Concerns Entries (USCDI Data Elements: Date of Resolution, Date of Diagnosis, SDOH Problems/Health Concerns, Health Concerns, Disability Status, Functional Status, Mental/Cognitive Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Condition Problems and Health Concerns Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 162. Composition.section:problemSection.entry:encounterDiagnosis | |||||
| Slice Name | encounterDiagnosis | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Encounter Diagnosis Entries (USCDI Data Elements: Encounter Diagnosis) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Condition Encounter Diagnosis Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 164. Composition.section:problemSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 166. Composition.section:problemSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 168. Composition.section:allergiesSection | |||||
| Slice Name | allergiesSection | ||||
| Definition | This section lists and describes all the patient's current allergies on the maintained allergy list. | ||||
| Short | Allergies Section (USCDI Data Class: Allergies and Intolerances) | ||||
| Control | 1..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 170. Composition.section:allergiesSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 172. Composition.section:allergiesSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 174. Composition.section:allergiesSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 176. Composition.section:allergiesSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 178. Composition.section:allergiesSection.code | |||||
| Definition | Allergies Section code | ||||
| Short | Allergies Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 180. Composition.section:allergiesSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 182. Composition.section:allergiesSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 184. Composition.section:allergiesSection.text | |||||
| Definition | Allergies Section narrative | ||||
| Short | Allergies Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 186. Composition.section:allergiesSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 188. Composition.section:allergiesSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 190. Composition.section:allergiesSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | AllergyIntolerance Entries (USCDI Data Elements: Substance (Medication), Substance (Drug Class), Reaction) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core AllergyIntolerance Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 192. Composition.section:allergiesSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 194. Composition.section:allergiesSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 196. Composition.section:assessmentAndPlanOfTreatmentSection | |||||
| Slice Name | assessmentAndPlanOfTreatmentSection | ||||
| Definition | Health professional’s conclusions and working assumptions that will guide treatment of the patient. | ||||
| Short | Assessment Section (USCDI Data Class: Assessment and Plan of Treatment, Health Status/Assessments) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 198. Composition.section:assessmentAndPlanOfTreatmentSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 200. Composition.section:assessmentAndPlanOfTreatmentSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 202. Composition.section:assessmentAndPlanOfTreatmentSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 204. Composition.section:assessmentAndPlanOfTreatmentSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 206. Composition.section:assessmentAndPlanOfTreatmentSection.code | |||||
| Definition | Assessment and Plan of Treatment Section code | ||||
| Short | Assessment and Plan of Treatment Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 208. Composition.section:assessmentAndPlanOfTreatmentSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 210. Composition.section:assessmentAndPlanOfTreatmentSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 212. Composition.section:assessmentAndPlanOfTreatmentSection.text | |||||
| Definition | Evaluation + Plan note | ||||
| Short | Evaluation + Plan note | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 214. Composition.section:assessmentAndPlanOfTreatmentSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 216. Composition.section:assessmentAndPlanOfTreatmentSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 218. Composition.section:assessmentAndPlanOfTreatmentSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 220. Composition.section:assessmentAndPlanOfTreatmentSection.entry:screeningAssessment | |||||
| Slice Name | screeningAssessment | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Assessment Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Observation Screening Assessment Profile, US Core Simple Observation Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Must Support Types | No must-support rules about the choice of types/profiles | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 222. Composition.section:assessmentAndPlanOfTreatmentSection.entry:questionnaireResponse | |||||
| Slice Name | questionnaireResponse | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | QuestionnaireResponse Entries (USCDI Data Elements: SDOH Assessment, Functional Status, Disability Status, Mental/Cogntive Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core QuestionnaireResponse Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 224. Composition.section:assessmentAndPlanOfTreatmentSection.entry:carePlan | |||||
| Slice Name | carePlan | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | CarePlan Entries (USCDI Data Elements: Assessment and Plan of Treatment) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core CarePlan Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 226. Composition.section:assessmentAndPlanOfTreatmentSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 228. Composition.section:assessmentAndPlanOfTreatmentSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 230. Composition.section:careTeamSection | |||||
| Slice Name | careTeamSection | ||||
| Definition | This section lists and describes all the patient's current care team members. | ||||
| Short | Care Team Section (USCDI Data Class: Care Team Members) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 232. Composition.section:careTeamSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 234. Composition.section:careTeamSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 236. Composition.section:careTeamSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 238. Composition.section:careTeamSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 240. Composition.section:careTeamSection.code | |||||
| Definition | Care Team Section code | ||||
| Short | Care Team Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 242. Composition.section:careTeamSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 244. Composition.section:careTeamSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 246. Composition.section:careTeamSection.text | |||||
| Definition | Care Team Section narrative | ||||
| Short | Care Team Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 248. Composition.section:careTeamSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 250. Composition.section:careTeamSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 252. Composition.section:careTeamSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Care Team Entries (USCDI Data Elements: Care Team Members - Name, Identifier, Location, Telecom, Role) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core CareTeam Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 254. Composition.section:careTeamSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 256. Composition.section:careTeamSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 258. Composition.section:coverageSection | |||||
| Slice Name | coverageSection | ||||
| Definition | This section lists the patient's coverage. | ||||
| Short | Coverage Section (USCDI Data Class: Health Insurance Information) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 260. Composition.section:coverageSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 262. Composition.section:coverageSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 264. Composition.section:coverageSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 266. Composition.section:coverageSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 268. Composition.section:coverageSection.code | |||||
| Definition | Coverage Section code | ||||
| Short | Coverage Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 270. Composition.section:coverageSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 272. Composition.section:coverageSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 274. Composition.section:coverageSection.text | |||||
| Definition | Coverage Section narrative | ||||
| Short | Coverage Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 276. Composition.section:coverageSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 278. Composition.section:coverageSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 280. Composition.section:coverageSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Coverage Entries (USCDI Data Elements: Coverage Status, Coverage Type, Relationship to Subscriber, Member Identifier, Subscriber Identifier, Group Number, Payer Identifier) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Coverage Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 282. Composition.section:coverageSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 284. Composition.section:coverageSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 286. Composition.section:goalsSection | |||||
| Slice Name | goalsSection | ||||
| Definition | This section lists and describes the patient's goals. | ||||
| Short | Goals Section (USCDI Data Class: Goals) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 288. Composition.section:goalsSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 290. Composition.section:goalsSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 292. Composition.section:goalsSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 294. Composition.section:goalsSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 296. Composition.section:goalsSection.code | |||||
| Definition | Goals Section code | ||||
| Short | Goals Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 298. Composition.section:goalsSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 300. Composition.section:goalsSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 302. Composition.section:goalsSection.text | |||||
| Definition | Goals Section narrative | ||||
| Short | Goals Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 304. Composition.section:goalsSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 306. Composition.section:goalsSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 308. Composition.section:goalsSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Goal Entries (USCDI Data Elements: Patient Goals, SDOH Goals) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Goal Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 310. Composition.section:goalsSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 312. Composition.section:goalsSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 314. Composition.section:immunizationsSection | |||||
| Slice Name | immunizationsSection | ||||
| Definition | The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section should include current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized. | ||||
| Short | Immunizations Section (USCDI Data Class: Immunization) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 316. Composition.section:immunizationsSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 318. Composition.section:immunizationsSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 320. Composition.section:immunizationsSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 322. Composition.section:immunizationsSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 324. Composition.section:immunizationsSection.code | |||||
| Definition | Immunizations code | ||||
| Short | Immunizations code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 326. Composition.section:immunizationsSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 328. Composition.section:immunizationsSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 330. Composition.section:immunizationsSection.text | |||||
| Definition | Immunizations narrative | ||||
| Short | Immunizations narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 332. Composition.section:immunizationsSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 334. Composition.section:immunizationsSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 336. Composition.section:immunizationsSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Immunization Entries (USCDI Data Elements: Immunizations) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Immunization Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 338. Composition.section:immunizationsSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 340. Composition.section:immunizationsSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 342. Composition.section:medicalEquipmentSection | |||||
| Slice Name | medicalEquipmentSection | ||||
| Definition | This section lists and describes all the patient's current implanted devices. | ||||
| Short | Medical Equipment Section (USCDI Data Class: Unique Device Identifier(s) for a patient's implantable device(s)) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 344. Composition.section:medicalEquipmentSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 346. Composition.section:medicalEquipmentSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 348. Composition.section:medicalEquipmentSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 350. Composition.section:medicalEquipmentSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 352. Composition.section:medicalEquipmentSection.code | |||||
| Definition | Medical Equipment Section code | ||||
| Short | Medical Equipment Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 354. Composition.section:medicalEquipmentSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 356. Composition.section:medicalEquipmentSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 358. Composition.section:medicalEquipmentSection.text | |||||
| Definition | Medical Equipment Section narrative | ||||
| Short | Medical Equipment Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 360. Composition.section:medicalEquipmentSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 362. Composition.section:medicalEquipmentSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 364. Composition.section:medicalEquipmentSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Implantable Device Entries (USCDI Data Elements: Unique Device Identifier(s) for a patient's implantable device(s)) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Implantable Device Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 366. Composition.section:medicalEquipmentSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 368. Composition.section:medicalEquipmentSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 370. Composition.section:medicationsSection | |||||
| Slice Name | medicationsSection | ||||
| Definition | The Medications Section contains a patient's current medications and pertinent medication history. At a minimum, the currently active medications are listed. | ||||
| Short | Medications Section (USCDI Data Class: Medications) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 372. Composition.section:medicationsSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 374. Composition.section:medicationsSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 376. Composition.section:medicationsSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 378. Composition.section:medicationsSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 380. Composition.section:medicationsSection.code | |||||
| Definition | Medications Section code | ||||
| Short | Medications Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 382. Composition.section:medicationsSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 384. Composition.section:medicationsSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 386. Composition.section:medicationsSection.text | |||||
| Definition | Medications Section narrative | ||||
| Short | Medications Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 388. Composition.section:medicationsSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 390. Composition.section:medicationsSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 392. Composition.section:medicationsSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 394. Composition.section:medicationsSection.entry:medicationAdministration | |||||
| Slice Name | medicationAdministration | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | MedicationAdministration Entries (USCDI Data Elements: Medications, Dose) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Health Care Surveys Medication Administration) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 396. Composition.section:medicationsSection.entry:medicationRequest | |||||
| Slice Name | medicationRequest | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | MedicationRequest Entries (USCDI Data Elements: Medications, Dose, Dose Unit of Measure, Indication) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core MedicationRequest Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 398. Composition.section:medicationsSection.entry:medicationDispense | |||||
| Slice Name | medicationDispense | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | MedicationDispense Entries (USCDI Data Elements: Medications, Fill Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core MedicationDispense Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 400. Composition.section:medicationsSection.entry:medication | |||||
| Slice Name | medication | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Medication Entries (USCDI Data Elements: Medications) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Medication Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 402. Composition.section:medicationsSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 404. Composition.section:medicationsSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 406. Composition.section:clinicalNotesSection | |||||
| Slice Name | clinicalNotesSection | ||||
| Definition | The Clinical Notes Section contains clinical notes and diagnostic reports. | ||||
| Short | Clinical Notes Section | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 408. Composition.section:clinicalNotesSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 410. Composition.section:clinicalNotesSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 412. Composition.section:clinicalNotesSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 414. Composition.section:clinicalNotesSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 416. Composition.section:clinicalNotesSection.code | |||||
| Definition | Clinical Notes Section code | ||||
| Short | Clinical Notes Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 418. Composition.section:clinicalNotesSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 420. Composition.section:clinicalNotesSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 422. Composition.section:clinicalNotesSection.text | |||||
| Definition | Clinical Notes Section narrative | ||||
| Short | Clinical Notes Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 424. Composition.section:clinicalNotesSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 426. Composition.section:clinicalNotesSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 428. Composition.section:clinicalNotesSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 430. Composition.section:clinicalNotesSection.entry:documentReference | |||||
| Slice Name | documentReference | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Document Reference Entries (USCDI Data Elements: Consultation Note, Discharge Summary Note, History & Physical, Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note, Progress Note) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core DocumentReference Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 432. Composition.section:clinicalNotesSection.entry:diagnosticReport | |||||
| Slice Name | diagnosticReport | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Diagnostic Report Entries (USCDI Data Elements: Imaging Narrative, Laboratory Report Narrative, Pathology Report Narrative, Procedure Note) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core DiagnosticReport Profile for Report and Note Exchange) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 434. Composition.section:clinicalNotesSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 436. Composition.section:clinicalNotesSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 438. Composition.section:pregnancySection | |||||
| Slice Name | pregnancySection | ||||
| Definition | This section contains pregnancy data | ||||
| Short | Pregnancy Section (USCDI Data Class: Health Status/Assessments - Pregnancy Status) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 440. Composition.section:pregnancySection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 442. Composition.section:pregnancySection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 444. Composition.section:pregnancySection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 446. Composition.section:pregnancySection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 448. Composition.section:pregnancySection.code | |||||
| Definition | Pregnancy Section code | ||||
| Short | Pregnancy Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 450. Composition.section:pregnancySection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 452. Composition.section:pregnancySection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 454. Composition.section:pregnancySection.text | |||||
| Definition | Pregnancy Section narrative | ||||
| Short | Pregnancy Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 456. Composition.section:pregnancySection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 458. Composition.section:pregnancySection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 460. Composition.section:pregnancySection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 462. Composition.section:pregnancySection.entry:pregnancyStatusObservation | |||||
| Slice Name | pregnancyStatusObservation | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pregnancy Status Entries (USCDI Data Elements: Pregnancy Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Observation Pregnancy Status Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 464. Composition.section:pregnancySection.entry:pregnancyIntent | |||||
| Slice Name | pregnancyIntent | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pregnancy Intent Entries (USCDI Data Elements: Pregnancy Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Observation Pregnancy Intent Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 466. Composition.section:pregnancySection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 468. Composition.section:pregnancySection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 470. Composition.section:proceduresSection | |||||
| Slice Name | proceduresSection | ||||
| Definition | This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. | ||||
| Short | Procedures Section (USCDI Data Class: Procedures) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 472. Composition.section:proceduresSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 474. Composition.section:proceduresSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 476. Composition.section:proceduresSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 478. Composition.section:proceduresSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 480. Composition.section:proceduresSection.code | |||||
| Definition | Procedures Section code | ||||
| Short | Procedures Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 482. Composition.section:proceduresSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 484. Composition.section:proceduresSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 486. Composition.section:proceduresSection.text | |||||
| Definition | Procedures Section narrative | ||||
| Short | Procedures Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 488. Composition.section:proceduresSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 490. Composition.section:proceduresSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 492. Composition.section:proceduresSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 494. Composition.section:proceduresSection.entry:procedure | |||||
| Slice Name | procedure | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Procedure Entries (USCDI Data Elements: Procedure, SDOH Interventions) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Procedure Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 496. Composition.section:proceduresSection.entry:procedureOrder | |||||
| Slice Name | procedureOrder | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Procedure Order Entries (USCDI Data Elements: Reason for Referral, SDOH Interventions) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core ServiceRequest Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 498. Composition.section:proceduresSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 500. Composition.section:proceduresSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 502. Composition.section:resultsSection | |||||
| Slice Name | resultsSection | ||||
| Definition | The Results Section contains observations of results generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy. | ||||
| Short | Results Section (USCDI Data Class: Laboratory, Clinical Tests) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 504. Composition.section:resultsSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 506. Composition.section:resultsSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 508. Composition.section:resultsSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 510. Composition.section:resultsSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 512. Composition.section:resultsSection.code | |||||
| Definition | Results Section code | ||||
| Short | Results Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 514. Composition.section:resultsSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 516. Composition.section:resultsSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 518. Composition.section:resultsSection.text | |||||
| Definition | Results Section narrative | ||||
| Short | Results Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 520. Composition.section:resultsSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 522. Composition.section:resultsSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 524. Composition.section:resultsSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 526. Composition.section:resultsSection.entry:result | |||||
| Slice Name | result | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Laboratory Result Observation Profile, US Core Observation Clinical Result Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Must Support Types | No must-support rules about the choice of types/profiles | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 528. Composition.section:resultsSection.entry:diagnosticReport | |||||
| Slice Name | diagnosticReport | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Diagnostic Result Entries (USCDI Data Elements: Laboratory Tests, Laboratory Values/Results, Laboratory Specimen Type, Laboratory Result Status, Clinical Test, Clinical Test Result/Report) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting, US Core DiagnosticReport Profile for Report and Note Exchange) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Must Support Types | No must-support rules about the choice of types/profiles | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 530. Composition.section:resultsSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 532. Composition.section:resultsSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 534. Composition.section:socialHistorySection | |||||
| Slice Name | socialHistorySection | ||||
| Definition | This section contains social history data that influence a patient’s physical, psychological or emotional health. | ||||
| Short | Social History Section (USCDI Data Class: Health Status/Assessments - Smoking Status, Patient Demographics/Information - Occupation, Occupation Industry) | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 536. Composition.section:socialHistorySection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 538. Composition.section:socialHistorySection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 540. Composition.section:socialHistorySection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 542. Composition.section:socialHistorySection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 544. Composition.section:socialHistorySection.code | |||||
| Definition | Social History Section code | ||||
| Short | Social History Section code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 546. Composition.section:socialHistorySection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 548. Composition.section:socialHistorySection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 550. Composition.section:socialHistorySection.text | |||||
| Definition | Social History Section narrative | ||||
| Short | Social History Section narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 552. Composition.section:socialHistorySection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 554. Composition.section:socialHistorySection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 556. Composition.section:socialHistorySection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 558. Composition.section:socialHistorySection.entry:smokingStatus | |||||
| Slice Name | smokingStatus | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Smoking Status Entries (USCDI Data Elements: Smoking Status) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Smoking Status Observation Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 560. Composition.section:socialHistorySection.entry:occupation | |||||
| Slice Name | occupation | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Occupation Entries (USCDI Data Elements: Occupation, Occupation Industry) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Observation Occupation Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 562. Composition.section:socialHistorySection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 564. Composition.section:socialHistorySection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 566. Composition.section:vitalSignsSection | |||||
| Slice Name | vitalSignsSection | ||||
| Definition | The Vital Signs Section contains relevant vital signs for the report. The section should include notable vital signs such as the most recent, maximum and/or minimum, baseline, or relevant trends. Vital signs are represented in the same way as other results, but are aggregated into their own section to follow clinical conventions. | ||||
| Short | Vital Signs Section (USCDI Data Class: Vital Signs) | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty())ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count())) | ||||
| 568. Composition.section:vitalSignsSection.id | |||||
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
| Short | Unique id for inter-element referencing | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 570. Composition.section:vitalSignsSection.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 572. Composition.section:vitalSignsSection.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
| Alternate Names | extensions, user content, modifiers | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||
| 574. Composition.section:vitalSignsSection.title | |||||
| Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
| Short | Label for section (e.g. for ToC) | ||||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
| Alternate Names | header, label, caption | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 576. Composition.section:vitalSignsSection.code | |||||
| Definition | Vital Signs code | ||||
| Short | Vital Signs code | ||||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1)Classification of a section of a composition/document. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Requirements | Provides computable standardized labels to topics within the document. | ||||
| Pattern Value | { | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 578. Composition.section:vitalSignsSection.author | |||||
| Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
| Short | Who and/or what authored the section | ||||
| Control | 0..* | ||||
| Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Identifies who is responsible for the content. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 580. Composition.section:vitalSignsSection.focus | |||||
| Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
| Short | Who/what the section is about, when it is not about the subject of composition | ||||
| Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
| Control | 0..1 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 582. Composition.section:vitalSignsSection.text | |||||
| Definition | Vital Signs narrative | ||||
| Short | Vital Signs narrative | ||||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
| Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
| Type | Narrative | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 584. Composition.section:vitalSignsSection.mode | |||||
| Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
| Short | working | snapshot | changes | ||||
| Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1)The processing mode that applies to this section. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| Summary | false | ||||
| Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 586. Composition.section:vitalSignsSection.orderedBy | |||||
| Definition | Specifies the order applied to the items in the section entries. | ||||
| Short | Order of section entries | ||||
| Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
| Control | 0..1 | ||||
| Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order|4.0.1)What order applies to the items in the entry. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 588. Composition.section:vitalSignsSection.entry | |||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | A reference to data that supports this section | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(Resource) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| Slicing | This element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 590. Composition.section:vitalSignsSection.entry:bloodPressure | |||||
| Slice Name | bloodPressure | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Blood Pressure Entries (USCDI Data Elements: Systolic Blood Pressure, Diastolic Blood Pressure) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Blood Pressure Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 592. Composition.section:vitalSignsSection.entry:bodyWeight | |||||
| Slice Name | bodyWeight | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Body Weight Entries (USCDI Data Elements: Body Weight) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Body Weight Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 594. Composition.section:vitalSignsSection.entry:bodyHeight | |||||
| Slice Name | bodyHeight | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Body Height Entries (USCDI Data Elements: Body Height) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Body Height Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 596. Composition.section:vitalSignsSection.entry:heartRate | |||||
| Slice Name | heartRate | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Heart Rate Entries (USCDI Data Elements: Heart Rate) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Heart Rate Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 598. Composition.section:vitalSignsSection.entry:pulseOximetry | |||||
| Slice Name | pulseOximetry | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pulse Oximetry Entries (USCDI Data Elements: Pulse Oximetry) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Pulse Oximetry Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 600. Composition.section:vitalSignsSection.entry:pediatricWeightForHeight | |||||
| Slice Name | pediatricWeightForHeight | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pediatric Weight For Height Entries (USCDI Data Elements: Pediatric Weight For Length Percentile (Birth to 36 months)) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Pediatric Weight for Height Observation Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 602. Composition.section:vitalSignsSection.entry:pediatricHeadOccipitalFrontalCircumference | |||||
| Slice Name | pediatricHeadOccipitalFrontalCircumference | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pediatric Head Occipital Frontal Circumference Percentile Entries (USCDI Data Elements: Occipital Frontal Head Circumference Percentile (Birth to 36 months)) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Pediatric Head Occipital Frontal Circumference Percentile Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 604. Composition.section:vitalSignsSection.entry:pediatricBMIForAge | |||||
| Slice Name | pediatricBMIForAge | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Pediatric BMI For Age Entries (USCDI Data Elements: BMI Percentile (2-20 years old)) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Pediatric BMI for Age Observation Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 606. Composition.section:vitalSignsSection.entry:bodyTemperature | |||||
| Slice Name | bodyTemperature | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Body Temperature Entries (USCDI Data Elements: Body Temperature) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Body Temperature Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 608. Composition.section:vitalSignsSection.entry:respiratoryRate | |||||
| Slice Name | respiratoryRate | ||||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
| Short | Respiratory Rate Entries (USCDI Data Elements: Respiratory Rate) | ||||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
| Type | Reference(US Core Respiratory Rate Profile) | ||||
| Is Modifier | false | ||||
| Must Support | true | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 610. Composition.section:vitalSignsSection.emptyReason | |||||
| Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
| Short | Why the section is empty | ||||
| Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
| Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
| Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1)If a section is empty, why it is empty. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 612. Composition.section:vitalSignsSection.section | |||||
| Definition | A nested sub-section within this section. | ||||
| Short | Nested Section | ||||
| Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
| Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||