International Patient Summary Implementation Guide
1.1.0 - CI Build
International Patient Summary Implementation Guide
1.1.0 - CI Build
International Patient Summary Implementation Guide, published by Health Level Seven International - Patient Care Work Group. This is not an authorized publication; it is the continuous build for version 1.1.0). This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips | Version: 1.1.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: CompositionUvIps | ||
Copyright/Legal: HL7 International |
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Clinical document used to represent the International Patient Summary (IPS) data set. An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. As specified in EN 17269 and ISO 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country.
This profile is based on the ClinicalDocument profile.
An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care, comprising at least the required elements of the IPS dataset. The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. As specified in EN 17269 and ISO 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country.
In this version of the guide the Medication Summary is expressed as a list of MedicationStatements or MedicationRequests. More information on medications lists are included in the Design Conventions and Principles page.
STU implementers are encouraged to provide their feedback about this design choice.
Particularly in light of the currect state of global health and the response to the COVID-19 pandemic due to the SARS-CoV-2 virus, extending the IPS Immunizations section to also include, when relevant, the status of immunity to specific target diseases is being considered. The potential updates to this implementation guide to incorporate this capability are still being discussed and have not been included in this initial published version of the guide. These proposed updates may include revising the Immunization section description to reflect this broadened scope (as IPS Immunizations/Immune Status Section, or similar), as a presumed or verified status of immunity to a disease is, in fact, the intended and desired outcome of a vaccination/immunization.
The capability to record a statement of immunity to a disease could be provided via a profile on the Condition resource and specific "immune status" codes (a set of "Finding of immune status" codes is currently available in SNOMED CT - however, at this time, a code representing "Immunity to COVID-19" or the equivalent is not available). The Condition resource may be appropriate for this purpose, as immunity (including, in some cases, a statement of "no immunity") is an ongoing state of the patient for some period of time (once immunity is acquired, typically for multiple years). The statement of immunity is not simply an observation at a point in time, although a statement of immunity would be expected in the case of COVID-19 and in many or most other cases to have associated observations that are necessary for providing the supporting evidence for the "immunity" condition.
As specific profiling is not yet available in the current IG publication to support the representation of a statement of immunity, the open slicing approach for including additional data in an IPS instance may be used. An example of of how this might be done is available in the 'immune-status' and potentially other branches of the IPS IG specification continuous integration (CI) build - link available by request from ips@lists.hl7.org or in the FHIR Zulip chat IPS Community of Practice stream.
Reviewers and implementers of this STU are encouraged to provide their feedback about this need and any questions, suggestions or concerns regarding the example profiles or other alternative approaches to addressing this situation. Any proposed solutions to be considered for inclusion in a future version of this guide will be subject to evaluation by the wider cross-SDO IPS community as well as the broader standards community and where possible relevant public health authorities (global, national and regional), in order to ensure to the extent possible that any solution that is adopted will be appropriate, usable and clinically sound.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Clinical Document | International Patient Summary composition | |
  text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| identifier | S | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
  type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Required Pattern: At least the following |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
 subject | S | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about |
| reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | 0..1 | Reference(Encounter) | Context of the Composition | |
| date | S | 1..1 | dateTime | Composition editing time |
| author | S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS |
| title | S | 1..1 | string | International Patient Summary |
| confidentiality | 0..1 | code | As defined by affinity domain | |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| mode | S | 1..1 | code | personal | professional | legal | official |
| time | S | 0..1 | dateTime | When the composition was attested |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | S | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| code | 1..1 | code | replaces | transforms | signs | appends | |
 target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition | Composition (IPS)) | |||
 Slices for event | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | |
  event:careProvisioningEvent | S | 0..1 | BackboneElement | The care provisioning being documented |
 code | S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
 period | S | 0..1 | Period | The period covered by the documentation |
| Slices for section | S | 1..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
 section:All Slices | Content/Rules for all slices | |||
  code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| emptyReason | 0..0 | |||
 section | 0..0 | |||
| section:sectionMedications | S | 1..1 | BackboneElement | IPS Medication Summary Section |
 title | S | 1..1 | string | Medication Summary section |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
 Slices for entry | S | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() |
| entry:medicationStatement | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
| entry:medicationRequest | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | |
| section:sectionAllergies | S | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry | S | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() |
| entry:allergyOrIntolerance | S | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
| section:sectionProblems | S | 1..1 | BackboneElement | IPS Problems Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry | S | 1..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() |
| entry:problem | S | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionProceduresHx | S | 0..1 | BackboneElement | IPS History of Procedures Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry | S | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() |
| entry:procedure | S | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizations | S | 0..1 | BackboneElement | IPS Immunizations Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry | S | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() |
| entry:immunization | S | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| section:sectionMedicalDevices | S | 0..1 | BackboneElement | IPS Medical Devices Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| Slices for entry | S | 1..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement | S | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResults | S | 0..1 | BackboneElement | IPS Results Section |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry | S | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:results-observation | S | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
| entry:results-diagnosticReport | S | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
| section:sectionVitalSigns | 0..1 | BackboneElement | IPS Vital Signs Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| Slices for entry | 0..* | Reference(Observation | DocumentReference) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:resolve() | |
| entry:vitalSign | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
| section:sectionPastIllnessHx | 0..1 | BackboneElement | IPS History of Past Illness Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry | 1..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() | |
| entry:pastProblem | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| section:sectionFunctionalStatus | 0..1 | BackboneElement | IPS Functional Status | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
| Slices for entry | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:resolve() | |
| entry:disability | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| entry:functionalAssessment | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
| section:sectionPlanOfCare | 0..1 | BackboneElement | IPS Plan of Care Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| Slices for entry | 0..* | Reference(CarePlan | DocumentReference) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:resolve() | |
| entry:carePlan | 0..* | Reference(CarePlan) | A reference to data that supports this section | |
| section:sectionSocialHistory | 0..1 | BackboneElement | IPS Social History Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
| Slices for entry | 0..* | Reference(Observation | DocumentReference) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:resolve() | |
| entry:smokingTobaccoUse | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
| entry:alcoholUse | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
| section:sectionPregnancyHx | 0..1 | BackboneElement | IPS History of Pregnancy Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
| Slices for entry | 0..* | Reference(Observation | DocumentReference) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:resolve() | |
| entry:pregnancyStatus | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | |
| entry:pregnancyOutcomeSummary | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section | |
| section:sectionAdvanceDirectives | 0..1 | BackboneElement | IPS Advance Directives Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
| Slices for entry | 0..* | Reference(Consent | DocumentReference) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:resolve() | |
| entry:advanceDirectivesConsent | 0..* | Reference(Consent) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Clinical Document | International Patient Summary composition | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about |
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date | SΣ | 1..1 | dateTime | Composition editing time |
| author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS |
| title | SΣ | 1..1 | string | International Patient Summary |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
| time | S | 0..1 | dateTime | When the composition was attested |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
| target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition | Composition (IPS)) | |||
| Slices for event | Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code |
| event:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning being documented |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
| period | SΣ | 0..1 | Period | The period covered by the documentation |
| Slices for section | SC | 1..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Medication Summary section |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry | SC | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() |
| entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
| entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section |
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry | SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() |
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
| section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry | SC | 1..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() |
| entry:problem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry | SC | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() |
| entry:procedure | SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizations | SC | 0..1 | BackboneElement | IPS Immunizations Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry | SC | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() |
| entry:immunization | SC | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| Slices for entry | SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement | SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResults | SC | 0..1 | BackboneElement | IPS Results Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry | SC | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:results-observation | SC | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
| entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
| section:sectionVitalSigns | C | 0..1 | BackboneElement | IPS Vital Signs Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
| Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:resolve() |
| entry:vitalSign | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
| section:sectionPastIllnessHx | C | 0..1 | BackboneElement | IPS History of Past Illness Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry | C | 1..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() |
| entry:pastProblem | C | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionFunctionalStatus | C | 0..1 | BackboneElement | IPS Functional Status |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
| Slices for entry | C | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:resolve() |
| entry:disability | C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| entry:functionalAssessment | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
| section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| Slices for entry | C | 0..* | Reference(CarePlan | DocumentReference) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:resolve() |
| entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| section:sectionSocialHistory | C | 0..1 | BackboneElement | IPS Social History Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
| Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:resolve() |
| entry:smokingTobaccoUse | C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
| entry:alcoholUse | C | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
| section:sectionPregnancyHx | C | 0..1 | BackboneElement | IPS History of Pregnancy Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
| Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:resolve() |
| entry:pregnancyStatus | C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section |
| entry:pregnancyOutcomeSummary | C | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section |
| section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
| Slices for entry | C | 0..* | Reference(Consent | DocumentReference) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:resolve() |
| entry:advanceDirectivesConsent | C | 0..* | Reference(Consent) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 60591-5 |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPR |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section:sectionMedications.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:sectionProblems.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC code 47519-4 |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC code 11369-6 |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC code 46264-8 |
| Composition.section:sectionResults.code | example | Pattern: LOINC code 30954-2 |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC code 8716-3 |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC code 11348-0 |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC code 47420-5 |
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC code 18776-5 |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC code 29762-2 |
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC code 10162-6 |
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC code 42348-3 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblems, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionMedicalDevices, Composition.section:sectionResults, Composition.section:sectionVitalSigns, Composition.section:sectionPastIllnessHx, Composition.section:sectionFunctionalStatus, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionPregnancyHx, Composition.section:sectionAdvanceDirectives | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblems, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionMedicalDevices, Composition.section:sectionResults, Composition.section:sectionVitalSigns, Composition.section:sectionPastIllnessHx, Composition.section:sectionFunctionalStatus, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionPregnancyHx, Composition.section:sectionAdvanceDirectives | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Clinical Document | International Patient Summary composition | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | Composition editing time | ||||
| author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS | ||||
| title | SΣ | 1..1 | string | International Patient Summary | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
| time | S | 0..1 | dateTime | When the composition was attested | ||||
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
| custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition | Composition (IPS)) | |||||||
| Slices for event | Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | ||||
| event:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | SΣ | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following | ||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| period | SΣ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 1..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Medication Summary section | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||
| entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
| entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() | ||||
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C |