International Patient Summary Implementation Guide
2.0.0 - STU 2
International Patient Summary Implementation Guide
2.0.0 - STU 2
International Patient Summary Implementation Guide, published by HL7 International / Patient Care. 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-ips/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips | Version: 2.0.0 | |||
| 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 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.
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 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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Composition | International Patient Summary composition dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
 text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children |
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
 type |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
| date |
SΣ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS ele-1: All FHIR elements must have a @value or children |
| title |
SΣ | 1..1 | string | International Patient Summary ele-1: All FHIR elements must have a @value or children |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children |
| time |
S | 0..1 | dateTime | When the composition was attested ele-1: All FHIR elements must have a @value or children |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition ele-1: All FHIR elements must have a @value or children |
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children |
 Slices for event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code ele-1: All FHIR elements must have a @value or children |
  event:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
  event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The care provisioning being documented ele-1: All FHIR elements must have a @value or children |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
 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. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children |
| Slices for section |
SC | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| section:All Slices |
Content/Rules for all slices | |||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| section:sectionProblems |
SC | 1..1 | BackboneElement | IPS Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:problem |
SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAllergies |
SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:allergyOrIntolerance |
SC | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionMedications |
SC | 1..1 | BackboneElement | IPS Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Medication Summary section ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:medicationStatement |
C | 0..* | Reference(MedicationStatement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:medicationRequest |
C | 0..* | Reference(MedicationRequest (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionImmunizations |
SC | 0..1 | BackboneElement | IPS Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:immunization |
SC | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionResults |
SC | 0..1 | BackboneElement | IPS Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | 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() ele-1: All FHIR elements must have a @value or children |
| entry:results-observation-laboratory-pathology |
SC | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:results-observation-radiology |
SC | 0..* | Reference(Observation Results - Radiology (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:results-diagnosticReport |
SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionProceduresHx |
SC | 0..1 | BackboneElement | IPS History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:procedure |
SC | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionMedicalDevices |
SC | 0..1 | BackboneElement | IPS Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:deviceStatement |
SC | 0..* | Reference(DeviceUseStatement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAdvanceDirectives |
C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:advanceDirectivesConsent |
C | 0..* | Reference(Consent) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAlerts |
C | 0..1 | BackboneElement | IPS Alerts Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 104605-1 | |
| Slices for entry |
C | 0..* | Reference(Flag | DocumentReference) | Alert information. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:alertsFlag |
C | 0..* | Reference(Flag - Alert (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionFunctionalStatus |
C | 0..1 | BackboneElement | IPS Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:disability |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:functionalAssessment |
C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPastIllnessHx |
C | 0..1 | BackboneElement | IPS History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | 0..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() ele-1: All FHIR elements must have a @value or children |
| entry:pastProblem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPregnancyHx |
C | 0..1 | BackboneElement | IPS History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:pregnancyStatus |
C | 0..* | Reference(Observation Pregnancy - Status (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:pregnancyOutcome |
C | 0..* | Reference(Observation Pregnancy - Outcome (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPatientStory |
C | 0..1 | BackboneElement | IPS Patient Story Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 81338-6 | |
| entry |
C | 0..* | Reference(Resource) | Patient Story resources. ele-1: All FHIR elements must have a @value or children |
| section:sectionPlanOfCare |
C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:carePlan |
C | 0..* | Reference(CarePlan) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionSocialHistory |
C | 0..1 | BackboneElement | IPS Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:smokingTobaccoUse |
C | 0..1 | Reference(Observation Social History - Tobacco Use (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:alcoholUse |
C | 0..1 | Reference(Observation Social History - Alcohol Use (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionVitalSigns |
C | 0..1 | BackboneElement | IPS Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | |
| code |
1..1 | CodeableConceptIPS | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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() ele-1: All FHIR elements must have a @value or children |
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | Pattern: LOINC Code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAlerts.code | example | Pattern: LOINC Code 104605-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPatientStory.code | example | Pattern: LOINC Code 81338-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionImmunizations, Composition.section:sectionResults, Composition.section:sectionProceduresHx, Composition.section:sectionMedicalDevices, Composition.section:sectionAdvanceDirectives, Composition.section:sectionAlerts, Composition.section:sectionFunctionalStatus, Composition.section:sectionPastIllnessHx, Composition.section:sectionPregnancyHx, Composition.section:sectionPatientStory, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionVitalSigns | 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:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionImmunizations, Composition.section:sectionResults, Composition.section:sectionProceduresHx, Composition.section:sectionMedicalDevices, Composition.section:sectionAdvanceDirectives, Composition.section:sectionAlerts, Composition.section:sectionFunctionalStatus, Composition.section:sectionPastIllnessHx, Composition.section:sectionPregnancyHx, Composition.section:sectionPatientStory, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionVitalSigns | 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() | |
| ips-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present : (entry.reference.exists() or emptyReason.exists()) |
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | 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 |
| 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 |
| 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 |
||||
 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 | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
| section:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| text |
S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section |
0..0 | |||
| section:sectionProblems |
SC | 1..1 | BackboneElement | IPS Problems Section ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() |
| entry:problem |
S | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionAllergies |
SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() |
| entry:allergyOrIntolerance |
S | 0..* | Reference(AllergyIntolerance (IPS)) | A reference to data that supports this section |
| section:sectionMedications |
SC | 1..1 | BackboneElement | IPS Medication Summary Section ips-comp-1: Either section.entry or emptyReason are present |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Medication Summary section |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | 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(MedicationStatement (IPS)) | A reference to data that supports this section | |
| entry:medicationRequest |
0..* | Reference(MedicationRequest (IPS)) | A reference to data that supports this section | |
| section:sectionImmunizations |
S | 0..1 | BackboneElement | IPS Immunizations Section |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() |
| entry:immunization |
S | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| section:sectionResults |
S | 0..1 | BackboneElement | IPS Results Section |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | 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-laboratory-pathology |
S | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS)) | A reference to data that supports this section |
| entry:results-observation-radiology |
S | 0..* | Reference(Observation Results - Radiology (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:sectionProceduresHx |
S | 0..1 | BackboneElement | IPS History of Procedures Section |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() |
| entry:procedure |
S | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionMedicalDevices |
S | 0..1 | BackboneElement | IPS Medical Devices Section |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
1..1 | CodeableConceptIPS | 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 | 0..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement |
S | 0..* | Reference(DeviceUseStatement (IPS)) | A reference to data that supports this section |
| section:sectionAdvanceDirectives |
0..1 | BackboneElement | IPS Advance Directives Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 | |
| section:sectionAlerts |
0..1 | BackboneElement | IPS Alerts Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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: 104605-1 | |
| Slices for entry |
0..* | Reference(Flag | DocumentReference) | Alert information. Slice: Unordered, Open by profile:resolve() | |
| entry:alertsFlag |
0..* | Reference(Flag - Alert (IPS)) | A reference to data that supports this section | |
| section:sectionFunctionalStatus |
0..1 | BackboneElement | IPS Functional Status | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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:sectionPastIllnessHx |
0..1 | BackboneElement | IPS History of Past Illness Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 |
0..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() | |
| entry:pastProblem |
0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| section:sectionPregnancyHx |
0..1 | BackboneElement | IPS History of Pregnancy Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 (IPS)) | A reference to data that supports this section | |
| entry:pregnancyOutcome |
0..* | Reference(Observation Pregnancy - Outcome (IPS)) | A reference to data that supports this section | |
| section:sectionPatientStory |
0..1 | BackboneElement | IPS Patient Story Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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: 81338-6 | |
| entry |
0..* | Reference(Resource) | Patient Story resources. | |
| section:sectionPlanOfCare |
0..1 | BackboneElement | IPS Plan of Care Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 Social History - Tobacco Use (IPS)) | A reference to data that supports this section | |
| entry:alcoholUse |
0..1 | Reference(Observation Social History - Alcohol Use (IPS)) | A reference to data that supports this section | |
| section:sectionVitalSigns |
0..1 | BackboneElement | IPS Vital Signs Section | |
| Slices for extension |
Content/Rules for all slices | |||
| section-note |
0..1 | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
1..1 | CodeableConceptIPS | 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 | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| ips-comp-1 | error | Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications | Either section.entry or emptyReason are present : (entry.reference.exists() or emptyReason.exists()) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | 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 | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| 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 |
SΣ | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | |||||
| |