International Patient Summary Implementation Guide
1.1.0 - CI Build International flag

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 1.1.0 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

Resource Profile: Composition (IPS)

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

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:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Clinical Document

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
.... 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..1 CodeableConcept Why the section is empty
..... section 0..0
.... section:sectionMedications SC 1..1 BackboneElement IPS Medication Summary Section
ips-comp-1: Either section.entry or emptyReason are present
..... 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 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(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 SC 1..1 BackboneElement IPS Allergies and Intolerances Section
ips-comp-1: Either section.entry or emptyReason are present
..... 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 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:resolve()
...... entry:allergyOrIntolerance S 0..* Reference(Allergy Intolerance (IPS)) A reference to data that supports this section
.... section:sectionProblems SC 1..1 BackboneElement IPS Problems Section
ips-comp-1: Either section.entry or emptyReason are present
..... 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 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: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 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: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 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: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 0..* Reference(DeviceUseStatement | DocumentReference) Patient history of medical device use.
Slice: Unordered, Open by profile:resolve()
...... entry:deviceStatement S 0..* 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 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 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 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: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

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
ips-comp-1errorComposition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblemsEither section.entry or emptyReason are present
: (entry.reference.exists() or emptyReason.exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... Slices for extension Content/Rules for all slices
.... versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... 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
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... 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
ips-comp-1: Either section.entry or emptyReason are present
..... 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 0..* 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
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
ips-comp-1: Either section.entry or emptyReason are present
..... 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 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:resolve()
...... entry:allergyOrIntolerance SC 0..* Reference(Allergy Intolerance (IPS)) A reference to data that supports this section
.... 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
ips-comp-1: Either section.entry or emptyReason are present
..... 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 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
...... entry:problem SC 0..* Reference(Condition (IPS)) A reference to data that supports this section
.... 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
..... 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 0..* Reference(Procedure | DocumentReference) Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
...... entry:procedure SC 0..* Reference(Procedure (IPS)) A reference to data that supports this section
.... 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
..... 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 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
...... entry:immunization SC 0..* Reference(Immunization (IPS)) A reference to data that supports this section
.... 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
..... 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 0..* Reference(DeviceUseStatement | DocumentReference) Patient history of medical device use.
Slice: Unordered, Open by profile:resolve()
...... entry:deviceStatement SC 0..* Reference(Device Use Statement (IPS)) A reference to data that supports this section
.... 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
..... 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 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 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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 0..* Reference(Condition | DocumentReference) Conditions the patient suffered in the past.
Slice: Unordered, Open by profile:resolve()
...... entry:pastProblem C 0..* Reference(Condition (IPS)) A reference to data that supports this section
.... 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
..... 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typepreferredPattern: LOINC code 60591-5
http://hl7.org/fhir/ValueSet/doc-typecodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event:careProvisioningEvent.codeexamplePattern: PCPR
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard
Composition.section:sectionMedications.codeexamplePattern: LOINC code 10160-0
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionAllergies.codeexamplePattern: LOINC code 48765-2
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionProblems.codeexamplePattern: LOINC code 11450-4
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionProceduresHx.codeexamplePattern: LOINC code 47519-4
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionImmunizations.codeexamplePattern: LOINC code 11369-6
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionMedicalDevices.codeexamplePattern: LOINC code 46264-8
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionResults.codeexamplePattern: LOINC code 30954-2
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionVitalSigns.codeexamplePattern: LOINC code 8716-3
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionPastIllnessHx.codeexamplePattern: LOINC code 11348-0
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionFunctionalStatus.codeexamplePattern: LOINC code 47420-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionPlanOfCare.codeexamplePattern: LOINC code 18776-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionSocialHistory.codeexamplePattern: LOINC code 29762-2
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionPregnancyHx.codeexamplePattern: LOINC code 10162-6
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section:sectionAdvanceDirectives.codeexamplePattern: LOINC code 42348-3
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.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:sectionAdvanceDirectivesA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.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:sectionAdvanceDirectivesA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ips-comp-1errorComposition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblemsEither section.entry or emptyReason are present
: (entry.reference.exists() or emptyReason.exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 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
.... 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 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-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
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 0..1 string Label for section (e.g. for ToC)
..... code 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
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... 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
ips-comp-1: Either section.entry or emptyReason are present
..... 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 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 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 0..* 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
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
ips-comp-1: Either section.entry or emptyReason are present
..... 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 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)