International Patient Summary Implementation Guide
1.0.0 - CI Build

International Patient Summary Implementation Guide, published by Health Level Seven International - Patient Care Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions

Resource Profile: CompositionUvIps

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/DIS 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.

The official URL for this profile is:

http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips

In this version of the guide the Medication Summary is expressed as a list of MedicationStatements. The reason for this choice is explained 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.

Formal Views of Profile Content

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

This structure is derived from Clinical Document

Summary

Mandatory: 19 elements (44 nested mandatory elements)
Must-Support: 110 elements
Prohibited: 28 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Composition.event is sliced based on the value of pattern:code
  • The element Composition.section is sliced based on the value of pattern:code
  • The element Composition.section.entry is sliced based on the value of profile:$this.resolve()
  • The element Composition.section.entry is sliced based on the values of type:$this.resolve(), profile:$this.resolve()

This structure is derived from Clinical Document

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition S0..*Clinical DocumentInternational Patient Summary composition
... text S0..1NarrativeText summary of the resource, for human interpretation
... identifier S0..1IdentifierVersion-independent identifier for the Composition
... status S1..1codepreliminary | final | amended | entered-in-error
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 60591-5
... subject S0..1Reference(Patient (IPS))Who and/or what the composition is about
.... reference S1..1stringLiteral reference, Relative, internal or absolute URL
... encounter S0..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the IPS
... title S1..1stringInternational Patient Summary
... confidentiality S0..1codeAs defined by affinity domain
... attester S0..*BackboneElementAttests to accuracy of composition
.... mode S1..1codepersonal | professional | legal | official
.... time S0..1dateTimeWhen the composition was attested
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian S0..1Reference(Organization)Organization which maintains the composition
... relatesTo S0..*BackboneElementRelationships to other compositions/documents
.... code S1..1codereplaces | transforms | signs | appends
.... target[x] S1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition | Composition (IPS))
... event S0..*(Slice Definition)The clinical service(s) being documented
Slice: Unordered, Open by pattern:code
.... event:careProvisioningEvent S0..1BackboneElementThe care provisioning being documented
..... code S1..*CodeableConceptCode(s) that apply to the event being documented
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: PCPR
..... period S0..1PeriodThe period covered by the documentation
... section S1..*(Slice Definition)Sections composing the IPS
Slice: Unordered, Open by pattern:code
.... section:sectionMedications S1..1BackboneElementIPS Medication Summary Section
..... title S1..1stringMedication Summary section
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:$this.resolve()
...... entry:medicationStatement S1..*Reference(Medication Statement (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionAllergies S1..1BackboneElementIPS Allergies and Intolerances Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:allergyOrIntolerance S1..*Reference(Allergy Intolerance (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionProblems S1..1BackboneElementIPS Problems Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:problem S1..*Reference(Condition (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionProceduresHx S0..1BackboneElementIPS History of Procedures Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47519-4
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:procedure S1..*Reference(Procedure (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionImmunizations S0..1BackboneElementIPS Immunizations Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11369-6
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:immunization S1..*Reference(Immunization (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionMedicalDevices S0..1BackboneElementIPS Medical Devices Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46264-8
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Patient history of medical device use.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:deviceStatement S1..*Reference(Device Use Statement (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionResults S0..1BackboneElementIPS Results Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve()
...... entry:results-observation S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))A reference to data that supports this section
...... entry:results-diagnosticReport S0..*Reference(DiagnosticReport (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionVitalSigns S0..1BackboneElementIPS Vital Signs Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S0..*(Slice Definition)Notable vital signs or physical findings.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:vitalSign S0..*Reference(Vital Signs Profile)A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionPastIllnessHx S0..1BackboneElementIPS History of Past Illness Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S1..*(Slice Definition)Conditions the patient suffered in the past.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:pastProblem S1..*Reference(Condition (IPS))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionFunctionalStatus S0..1BackboneElementIPS Functional Status
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47420-5
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S0..*(Slice Definition)Optional entry used to represent disabilities and functional assessments
Slice: Unordered, Open by profile:$this.resolve()
...... entry:disability S0..*Reference(Condition (IPS))A reference to data that supports this section
...... entry:functionalAssessment S0..*Reference(ClinicalImpression)A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionPlanOfCare S0..1BackboneElementIPS Plan of Care Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 18776-5
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry 0..*(Slice Definition)Optional entry used to represent structured care plans
Slice: Unordered, Open by profile:$this.resolve()
...... entry:carePlan 0..*Reference(CarePlan)A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionSocialHistory S0..1BackboneElementIPS Social History Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 29762-2
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S0..*(Slice Definition)Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Slice: Unordered, Open by profile:$this.resolve()
...... entry:smokingTobaccoUse S0..1Reference(Observation (SH: tobacco use))A reference to data that supports this section
...... entry:alcoholUse S0..1Reference(Observation (SH: alcohol use))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionPregnancyHx S0..1BackboneElementIPS History of Pregnancy Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S0..*(Slice Definition)Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:pregnancyStatus S0..*Reference(Observation (Pregnancy: status))A reference to data that supports this section
...... entry:pregnancyOutcomeSummary S0..*Reference(Observation (Pregnancy: outcome))A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0
.... section:sectionAdvanceDirectives S0..1BackboneElementIPS Advance Directives Section
..... title S1..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 42348-3
..... text S1..1NarrativeText summary of the section, for human interpretation
..... entry S0..*(Slice Definition)Narrative description of the patient's advance directive.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:advanceDirectivesConsent S0..*Reference(Consent)A reference to data that supports this section
..... emptyReason 0..0
..... section 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition SI0..*Clinical DocumentInternational Patient Summary composition
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text SI0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionExtension
Slice: Unordered, Open by value:url
... composition-clinicaldocument-versionNumber I0..*stringVersion-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SI1..1CodeableConceptIPSKind of composition ("Patient Summary")
Binding: FHIRDocumentTypeCodes (preferred)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 60591-5
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣI0..1Reference(Patient (IPS))Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... encounter SΣI0..1Reference(Encounter)Context of the Composition
... date SΣI1..1dateTimeComposition editing time
... author SΣI1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the IPS
... title SΣI1..1stringInternational Patient Summary
... confidentiality SΣI0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required)
... attester SI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode SI1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time SI0..1dateTimeWhen the composition was attested
.... party SI0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian SΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo SI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code SI1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] SI1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition | Composition (IPS))
... event SΣI0..*(Slice Definition)The clinical service(s) being documented
Slice: Unordered, Open by pattern:code
.... event:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code ΣI0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
..... period ΣI0..1PeriodThe period covered by the documentation
..... detail ΣI0..*Reference(Resource)The event(s) being documented
.... event:careProvisioningEvent SΣI0..1BackboneElementThe care provisioning being documented
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code SΣI1..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)

Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: PCPR
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... period SΣI0..1PeriodThe period covered by the documentation
..... detail ΣI0..*Reference(Resource)The event(s) being documented
... section SI1..*(Slice Definition)Sections composing the IPS
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title I0..1stringLabel for section (e.g. for ToC)
..... code I0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry I0..*Reference(Resource)A reference to data that supports this section
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
..... section I0..*Unknown reference to #Composition.section
Nested Section
.... section:sectionMedications SI1..1BackboneElementIPS Medication Summary Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringMedication Summary section
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:$this.resolve()
...... entry:medicationStatement SI1..*Reference(Medication Statement (IPS))A reference to data that supports this section
.... section:sectionAllergies SI1..1BackboneElementIPS Allergies and Intolerances Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:allergyOrIntolerance SI1..*Reference(Allergy Intolerance (IPS))A reference to data that supports this section
.... section:sectionProblems SI1..1BackboneElementIPS Problems Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:problem SI1..*Reference(Condition (IPS))A reference to data that supports this section
.... section:sectionProceduresHx SI0..1BackboneElementIPS History of Procedures Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 47519-4
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:procedure SI1..*Reference(Procedure (IPS))A reference to data that supports this section
.... section:sectionImmunizations SI0..1BackboneElementIPS Immunizations Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11369-6
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:immunization SI1..*Reference(Immunization (IPS))A reference to data that supports this section
.... section:sectionMedicalDevices SI0..1BackboneElementIPS Medical Devices Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 46264-8
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Patient history of medical device use.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:deviceStatement SI1..*Reference(Device Use Statement (IPS))A reference to data that supports this section
.... section:sectionResults SI0..1BackboneElementIPS Results Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 30954-2
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI1..*(Slice Definition)Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve()
...... entry:results-observation SI0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))A reference to data that supports this section
...... entry:results-diagnosticReport SI0..*Reference(DiagnosticReport (IPS))A reference to data that supports this section
.... section:sectionVitalSigns SI0..1BackboneElementIPS Vital Signs Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text SI1..1NarrativeText summary of the section, for human interpretation
..... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
..... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
..... entry SI0..*(Slice Definition)Notable vital signs or physical findings.
Slice: Unordered, Open by profile:$this.resolve()
...... entry:vitalSign SI0..*Reference(Vital Signs Profile)A reference to data that supports this section
.... section:sectionPastIllnessHx SI0..1BackboneElementIPS History of Past Illness Section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title SI1..1stringLabel for section (e.g. for ToC)
..... code SI1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DocumentSectionCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11348-0
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
.