IPS-CL
0.1.0 - ci-build
IPS-CL
0.1.0 - ci-build
IPS-CL, published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/IPS-CL/ and changes regularly. See the Directory of published versions
| Official URL: https://hl7chile.cl/fhir/ig/clips/StructureDefinition/Composition-cl-ips | Version: 0.1.0 | |||
| Standards status: Draft | Maturity Level: 1 | Computable Name: DocumentoClIps | ||
Copyright/Legal: HL7 International |
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Documento clínico utilizado para representar el conjunto de datos del Resumen Internacional de Pacientes (IPS). Un documento de Resumen Internacional de Paciente (IPS) es un extracto de historia clínica electrónica que contiene información sanitaria esencial sobre un sujeto de atención. El conjunto de datos IPS es mínimo y no exhaustivo; independiente de la especialidad y la afección; pero sigue siendo clínicamente relevante. Tal como se especifica en las normas EN 17269 e ISO 27269, está diseñado para apoyar el caso de uso de la «atención transfronteriza no planificada», pero no se limita a él. Pretende ser internacional, es decir, ofrecer soluciones genéricas para su aplicación global más allá de una región o país concretos.
Este perfil se basa en el perfil ClinicalDocument.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Composition | International Patient Summary Documento | |
  text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error |
  type |
S | 1..1 | CodeableConceptIPS | Tipo de Documento ("Resumen de Paciente") Required Pattern: At least the following |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
 subject |
S | 1..1 | Reference(Paciente IPS-CL) | Who and/or what the composition is about |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Quén o/y fué el autor del IPS |
| title |
S | 1..1 | string | International Patient Summary Genérico para uso en Chile |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition |
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian |
S | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo |
||||
 target[x] |
1..1 | Target of the relationship | ||
| targetIdentifier |
Identifier | |||
| targetReference |
Reference(Composition | Documento (IPS-CL)) | |||
 Slices for event |
0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | |
  event:careProvisioningEvent |
S | 0..1 | BackboneElement | La asistencia descrita en el documento |
 code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
 period |
S | 0..1 | Period | The period covered by the documentation |
| Slices for section |
S | 3..* | BackboneElement | Secciones que componen el IPS Slice: Unordered, Open by pattern:code |
 section:All Slices |
Content/Rules for all slices | |||
  code |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| text |
S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| emptyReason |
0..0 | |||
 section |
0..0 | |||
| section:sectionMedicamentos |
S | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS |
 title |
S | 1..1 | string | Sección de Resumen de Medicamentos |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
 Slices for entry |
S | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() |
| entry:listMEdicamentos |
0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section | |
| entry:prescripciones |
0..* | Reference(Medication Request (IPS-CL)) | A reference to data that supports this section | |
| section:sectionAlergias |
S | 1..1 | BackboneElement | Sección de Alergias e Intolerancias |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry |
S | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() |
| entry:alergias |
S | 1..* | Reference(Alergias e Intolerancias IPS-CL) | A reference to data that supports this section |
| section:sectionProblemas |
S | 1..1 | BackboneElement | Problemas de Salud |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry |
S | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() |
| entry:problema |
S | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionProcedimientos |
S | 0..1 | BackboneElement | Historial de Procedimientos |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry |
S | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() |
| entry:procedimiento |
S | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizaciones |
S | 0..1 | BackboneElement | Sección de Inmunizaciones |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry |
S | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() |
| entry:immunizacion |
S | 1..* | Reference(Immunización (IPS-CL)) | A reference to data that supports this section |
| section:sectionDispMedicos |
S | 0..1 | BackboneElement | Sección de Dispositivos Médicos |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| Slices for entry |
S | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement |
S | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResultados |
S | 0..1 | BackboneElement | Sección de Resultados |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry |
S | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:resultados-obs-lab-pato |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section |
| entry:resultados-obs-radio |
S | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section |
| entry:resultado-reporte |
S | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | A reference to data that supports this section |
| section:sectionSignosVitales |
0..1 | BackboneElement | Sección de Signos Vitales | |
| 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) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() | |
| entry:vitalSign |
0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
| section:sectionHistoricoHx |
0..1 | BackboneElement | Histórico de enfermedades | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry |
1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() | |
| entry:pastProblem |
1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | |
| section:sectionStatusFuncional |
0..1 | BackboneElement | Status Funcional | |
| 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) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() | |
| entry:discapacidad |
0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | |
| entry:evalFuncional |
0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
| section:sectionPlanCuidado |
0..1 | BackboneElement | Plan de Cuidado | |
| 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) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() | |
| entry:carePlan |
0..* | Reference(CarePlan) | A reference to data that supports this section | |
| section:sectionHistoriaSocial |
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) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() | |
| entry:fumador |
0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
| entry:alcohol |
0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
| section:sectionEmbarazoHx |
0..1 | BackboneElement | Historial de Embarazos | |
| 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) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() | |
| entry:statusEmbarazo |
0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | |
| entry:resultadoEmbarazo |
0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section | |
| section:sectionDirectivasAvanzadas |
0..1 | BackboneElement | Sección de Concentimientos | |
| 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) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() | |
| entry:advanceDirectivesConsent |
0..* | Reference(Consent) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | International Patient Summary Documento | |
 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 |
 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 | Tipo de Documento ("Resumen de Paciente") 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(Paciente IPS-CL) | Who and/or what the composition is about |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Quén o/y fué el autor del IPS |
| title |
SΣ | 1..1 | string | International Patient Summary Genérico para uso en Chile |
| 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 |
| 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 | La asistencia descrita en el documento |
| 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 | 3..* | BackboneElement | Secciones que componen el 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 |
| section:sectionMedicamentos |
SC | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS 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 | Sección de Resumen de Medicamentos |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry |
SC | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() |
| entry:listMEdicamentos |
C | 0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section |
| entry:prescripciones |
C | 0..* | Reference(Medication Request (IPS-CL)) | A reference to data that supports this section |
| section:sectionAlergias |
SC | 1..1 | BackboneElement | Sección de Alergias e Intolerancias 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: 48765-2 | |
| Slices for entry |
SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() |
| entry:alergias |
SC | 1..* | Reference(Alergias e Intolerancias IPS-CL) | A reference to data that supports this section |
| section:sectionProblemas |
SC | 1..1 | BackboneElement | Problemas de Salud 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: 11450-4 | |
| Slices for entry |
SC | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() |
| entry:problema |
SC | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionProcedimientos |
SC | 0..1 | BackboneElement | Historial de Procedimientos 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 | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() |
| entry:procedimiento |
SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizaciones |
SC | 0..1 | BackboneElement | Sección de Inmunizaciones 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 | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() |
| entry:immunizacion |
SC | 1..* | Reference(Immunización (IPS-CL)) | A reference to data that supports this section |
| section:sectionDispMedicos |
SC | 0..1 | BackboneElement | Sección de Dispositivos Médicos 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 | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement |
SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResultados |
SC | 0..1 | BackboneElement | Sección de Resultados 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 | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:resultados-obs-lab-pato |
SC | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section |
| entry:resultados-obs-radio |
SC | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section |
| entry:resultado-reporte |
SC | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | A reference to data that supports this section |
| section:sectionSignosVitales |
C | 0..1 | BackboneElement | Sección de Signos Vitales 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) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() |
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
| section:sectionHistoricoHx |
C | 0..1 | BackboneElement | Histórico de enfermedades 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 | 1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() |
| entry:pastProblem |
C | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionStatusFuncional |
C | 0..1 | BackboneElement | Status Funcional 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) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() |
| entry:discapacidad |
C | 0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| entry:evalFuncional |
C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
| section:sectionPlanCuidado |
C | 0..1 | BackboneElement | Plan de Cuidado 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) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() |
| entry:carePlan |
C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| section:sectionHistoriaSocial |
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) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() |
| entry:fumador |
C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
| entry:alcohol |
C | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
| section:sectionEmbarazoHx |
C | 0..1 | BackboneElement | Historial de Embarazos 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) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() |
| entry:statusEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section |
| entry:resultadoEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section |
| section:sectionDirectivasAvanzadas |
C | 0..1 | BackboneElement | Sección de Concentimientos 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) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() |
| entry:advanceDirectivesConsent |
C | 0..* | Reference(Consent) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | Pattern: LOINC Code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAlergias.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProblemas.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProcedimientos.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizaciones.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDispMedicos.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResultados.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSignosVitales.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionHistoricoHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionStatusFuncional.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPlanCuidado.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionHistoriaSocial.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionEmbarazoHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDirectivasAvanzadas.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | International Patient Summary Documento | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
S | 1..1 | CodeableConceptIPS | Tipo de Documento ("Resumen de Paciente") 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(Paciente IPS-CL) | 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) | Quén o/y fué el autor del IPS | ||||
| title |
SΣ | 1..1 | string | International Patient Summary Genérico para uso en Chile | ||||
| 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 | Documento (IPS-CL)) | |||||||
| 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 | La asistencia descrita en el documento | ||||
| 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 | 3..* | BackboneElement | Secciones que componen el 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 | ||||
| section:sectionMedicamentos |
SC | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS 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 | ||||
| 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 | Sección de Resumen de Medicamentos | ||||
| 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 | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() | ||||
| entry:listMEdicamentos |
C | 0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section | ||||
| entry:prescripciones |
C | 0..* | Reference(Medication Request (IPS-CL)) | 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:sectionAlergias |
SC | 1..1 | BackboneElement | Sección de Alergias e Intolerancias 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 | ||||
| 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) | |||||
| 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: 48765-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:alergias |
SC | 1..* | Reference(Alergias e Intolerancias IPS-CL) | 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:sectionProblemas |
SC | 1..1 | BackboneElement | Problemas de Salud 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 | ||||
| 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) | |||||
| 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: 11450-4 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:problema |
SC | 1..* | Reference(Condición (IPS-CL)) | 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:sectionProcedimientos |
SC | 0..1 | BackboneElement | Historial de Procedimientos 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 | ||||
| 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) | |||||
| 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: 47519-4 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedimiento |
SC | 1..* | Reference(Procedure (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:sectionImmunizaciones |
SC | 0..1 | BackboneElement | Sección de Inmunizaciones 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 | ||||
| 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) | |||||
| 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: 11369-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizacion |
SC | 1..* | Reference(Immunización (IPS-CL)) | 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:sectionDispMedicos |
SC | 0..1 | BackboneElement | Sección de Dispositivos Médicos 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 | ||||
| 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) | |||||
| 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: 46264-8 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() | ||||
| entry:deviceStatement |
SC | 1..* | Reference(Device Use Statement (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:sectionResultados |
SC | 0..1 | BackboneElement | Sección de Resultados 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 | ||||
| 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) | |||||
| 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: 30954-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() | ||||
| entry:resultados-obs-lab-pato |
SC | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section | ||||
| entry:resultados-obs-radio |
SC | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section | ||||
| entry:resultado-reporte |
SC | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | 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:sectionSignosVitales |
C | 0..1 | BackboneElement | Sección de Signos Vitales 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 | ||||
| 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 |
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) | |||||
| 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: 8716-3 | |||||
| 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 |
C | 0..* | Reference(Observation | DocumentReference) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() | ||||
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | 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:sectionHistoricoHx |
C | 0..1 | BackboneElement | Histórico de enfermedades 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 | ||||
| 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 |
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) | |||||
| 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: 11348-0 | |||||
| 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 |
C | 1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() | ||||
| entry:pastProblem |
C | 1..* | Reference(Condición (IPS-CL)) | 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:sectionStatusFuncional |
C | 0..1 | BackboneElement | Status Funcional 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 | ||||
| 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 |
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) | |||||
| 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: 47420-5 | |||||
| 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 | |||||
| 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 |
C | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() | ||||
| entry:discapacidad |
C | 0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | ||||
| entry:evalFuncional |
C | 0..* | Reference(ClinicalImpression) | 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:sectionPlanCuidado |
C | 0..1 | BackboneElement | Plan de Cuidado 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 | ||||
| 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 |
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) | |||||
| 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: 18776-5 | |||||
| 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 | |||||
| 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 |
C | 0..* | Reference(CarePlan | DocumentReference) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() | ||||
| entry:carePlan |
C | 0..* | Reference(CarePlan) | 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:sectionHistoriaSocial |
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 | ||||
| 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 |
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) | |||||
| 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: 29762-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
C | 0..* | Reference(Observation | DocumentReference) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() | ||||
| entry:fumador |
C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | ||||
| entry:alcohol |
C | 0..1 | Reference(Observation - SH: alcohol use) | 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:sectionEmbarazoHx |
C | 0..1 | BackboneElement | Historial de Embarazos 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 | ||||
| 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 |
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) | |||||
| 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: 10162-6 | |||||
| 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 |
C | 0..* | Reference(Observation | DocumentReference) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() | ||||
| entry:statusEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | ||||
| entry:resultadoEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: outcome) | 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:sectionDirectivasAvanzadas |
C | 0..1 | BackboneElement | Sección de Concentimientos 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 | ||||
| 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 |
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) | |||||
| 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: 42348-3 | |||||
| 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 |
C | 0..* | Reference(Consent | DocumentReference) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:advanceDirectivesConsent |
C | 0..* | Reference(Consent) | 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | Pattern: LOINC Code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionAlergias.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionProblemas.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionResultados.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 15 elements(21 nested mandatory elements)
Must-Support: 49 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 1
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | International Patient Summary Documento | |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type |
S | 1..1 | CodeableConceptIPS | Tipo de Documento ("Resumen de Paciente") Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
| subject |
S | 1..1 | Reference(Paciente IPS-CL) | Who and/or what the composition is about |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Quén o/y fué el autor del IPS |
| title |
S | 1..1 | string | International Patient Summary Genérico para uso en Chile |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition |
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian |
S | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo |
||||
| target[x] |
1..1 | Target of the relationship | ||
| targetIdentifier |
Identifier | |||
| targetReference |
Reference(Composition | Documento (IPS-CL)) | |||
| Slices for event |
0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | |
| event:careProvisioningEvent |
S | 0..1 | BackboneElement | La asistencia descrita en el documento |
| code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
| period |
S | 0..1 | Period | The period covered by the documentation |
| Slices for section |
S | 3..* | BackboneElement | Secciones que componen el IPS Slice: Unordered, Open by pattern:code |
| section:All Slices |
Content/Rules for all slices | |||
| code |
S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| text |
S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| emptyReason |
0..0 | |||
| section |
0..0 | |||
| section:sectionMedicamentos |
S | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS |
| title |
S | 1..1 | string | Sección de Resumen de Medicamentos |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry |
S | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() |
| entry:listMEdicamentos |
0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section | |
| entry:prescripciones |
0..* | Reference(Medication Request (IPS-CL)) | A reference to data that supports this section | |
| section:sectionAlergias |
S | 1..1 | BackboneElement | Sección de Alergias e Intolerancias |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry |
S | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() |
| entry:alergias |
S | 1..* | Reference(Alergias e Intolerancias IPS-CL) | A reference to data that supports this section |
| section:sectionProblemas |
S | 1..1 | BackboneElement | Problemas de Salud |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry |
S | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() |
| entry:problema |
S | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionProcedimientos |
S | 0..1 | BackboneElement | Historial de Procedimientos |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry |
S | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() |
| entry:procedimiento |
S | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizaciones |
S | 0..1 | BackboneElement | Sección de Inmunizaciones |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry |
S | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() |
| entry:immunizacion |
S | 1..* | Reference(Immunización (IPS-CL)) | A reference to data that supports this section |
| section:sectionDispMedicos |
S | 0..1 | BackboneElement | Sección de Dispositivos Médicos |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| Slices for entry |
S | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement |
S | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResultados |
S | 0..1 | BackboneElement | Sección de Resultados |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry |
S | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:resultados-obs-lab-pato |
S | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section |
| entry:resultados-obs-radio |
S | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section |
| entry:resultado-reporte |
S | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | A reference to data that supports this section |
| section:sectionSignosVitales |
0..1 | BackboneElement | Sección de Signos Vitales | |
| 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) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() | |
| entry:vitalSign |
0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
| section:sectionHistoricoHx |
0..1 | BackboneElement | Histórico de enfermedades | |
| title |
1..1 | string | Label for section (e.g. for ToC) | |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry |
1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() | |
| entry:pastProblem |
1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | |
| section:sectionStatusFuncional |
0..1 | BackboneElement | Status Funcional | |
| 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) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() | |
| entry:discapacidad |
0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | |
| entry:evalFuncional |
0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
| section:sectionPlanCuidado |
0..1 | BackboneElement | Plan de Cuidado | |
| 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) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() | |
| entry:carePlan |
0..* | Reference(CarePlan) | A reference to data that supports this section | |
| section:sectionHistoriaSocial |
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) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() | |
| entry:fumador |
0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
| entry:alcohol |
0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
| section:sectionEmbarazoHx |
0..1 | BackboneElement | Historial de Embarazos | |
| 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) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() | |
| entry:statusEmbarazo |
0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | |
| entry:resultadoEmbarazo |
0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section | |
| section:sectionDirectivasAvanzadas |
0..1 | BackboneElement | Sección de Concentimientos | |
| 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) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() | |
| entry:advanceDirectivesConsent |
0..* | Reference(Consent) | A reference to data that supports this section | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | International Patient Summary Documento | |
| 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 |
| 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 | Tipo de Documento ("Resumen de Paciente") 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(Paciente IPS-CL) | Who and/or what the composition is about |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Quén o/y fué el autor del IPS |
| title |
SΣ | 1..1 | string | International Patient Summary Genérico para uso en Chile |
| 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 |
| 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 | La asistencia descrita en el documento |
| 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 | 3..* | BackboneElement | Secciones que componen el 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 |
| section:sectionMedicamentos |
SC | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS 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 | Sección de Resumen de Medicamentos |
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry |
SC | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() |
| entry:listMEdicamentos |
C | 0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section |
| entry:prescripciones |
C | 0..* | Reference(Medication Request (IPS-CL)) | A reference to data that supports this section |
| section:sectionAlergias |
SC | 1..1 | BackboneElement | Sección de Alergias e Intolerancias 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: 48765-2 | |
| Slices for entry |
SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() |
| entry:alergias |
SC | 1..* | Reference(Alergias e Intolerancias IPS-CL) | A reference to data that supports this section |
| section:sectionProblemas |
SC | 1..1 | BackboneElement | Problemas de Salud 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: 11450-4 | |
| Slices for entry |
SC | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() |
| entry:problema |
SC | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionProcedimientos |
SC | 0..1 | BackboneElement | Historial de Procedimientos 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 | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() |
| entry:procedimiento |
SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizaciones |
SC | 0..1 | BackboneElement | Sección de Inmunizaciones 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 | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() |
| entry:immunizacion |
SC | 1..* | Reference(Immunización (IPS-CL)) | A reference to data that supports this section |
| section:sectionDispMedicos |
SC | 0..1 | BackboneElement | Sección de Dispositivos Médicos 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 | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() |
| entry:deviceStatement |
SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResultados |
SC | 0..1 | BackboneElement | Sección de Resultados 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 | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() |
| entry:resultados-obs-lab-pato |
SC | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section |
| entry:resultados-obs-radio |
SC | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section |
| entry:resultado-reporte |
SC | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | A reference to data that supports this section |
| section:sectionSignosVitales |
C | 0..1 | BackboneElement | Sección de Signos Vitales 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) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() |
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
| section:sectionHistoricoHx |
C | 0..1 | BackboneElement | Histórico de enfermedades 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 | 1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() |
| entry:pastProblem |
C | 1..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| section:sectionStatusFuncional |
C | 0..1 | BackboneElement | Status Funcional 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) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() |
| entry:discapacidad |
C | 0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section |
| entry:evalFuncional |
C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
| section:sectionPlanCuidado |
C | 0..1 | BackboneElement | Plan de Cuidado 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) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() |
| entry:carePlan |
C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| section:sectionHistoriaSocial |
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) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() |
| entry:fumador |
C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
| entry:alcohol |
C | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
| section:sectionEmbarazoHx |
C | 0..1 | BackboneElement | Historial de Embarazos 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) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() |
| entry:statusEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section |
| entry:resultadoEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section |
| section:sectionDirectivasAvanzadas |
C | 0..1 | BackboneElement | Sección de Concentimientos 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) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() |
| entry:advanceDirectivesConsent |
C | 0..* | Reference(Consent) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | Pattern: LOINC Code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAlergias.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProblemas.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProcedimientos.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizaciones.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDispMedicos.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResultados.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSignosVitales.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionHistoricoHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionStatusFuncional.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPlanCuidado.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionHistoriaSocial.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionEmbarazoHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDirectivasAvanzadas.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | International Patient Summary Documento | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
S | 1..1 | CodeableConceptIPS | Tipo de Documento ("Resumen de Paciente") 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(Paciente IPS-CL) | 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) | Quén o/y fué el autor del IPS | ||||
| title |
SΣ | 1..1 | string | International Patient Summary Genérico para uso en Chile | ||||
| 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 | Documento (IPS-CL)) | |||||||
| 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 | La asistencia descrita en el documento | ||||
| 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 | 3..* | BackboneElement | Secciones que componen el 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 | ||||
| section:sectionMedicamentos |
SC | 1..1 | BackboneElement | Sección de Resumen de Medicamentos IPS 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 | ||||
| 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 | Sección de Resumen de Medicamentos | ||||
| 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 | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medicamentos relevantes para la salud del paciente Slice: Unordered, Open by profile:resolve() | ||||
| entry:listMEdicamentos |
C | 0..* | Reference(Medication Statement (IPS-CL)) | A reference to data that supports this section | ||||
| entry:prescripciones |
C | 0..* | Reference(Medication Request (IPS-CL)) | 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:sectionAlergias |
SC | 1..1 | BackboneElement | Sección de Alergias e Intolerancias 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 | ||||
| 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) | |||||
| 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: 48765-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(AllergyIntolerance | DocumentReference) | Alergias o intolerancias (afecciones) relevantes para ese paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:alergias |
SC | 1..* | Reference(Alergias e Intolerancias IPS-CL) | 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:sectionProblemas |
SC | 1..1 | BackboneElement | Problemas de Salud 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 | ||||
| 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) | |||||
| 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: 11450-4 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Condition | DocumentReference) | Problemas o afecciones clínicas que se están controlando actualmente en el paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:problema |
SC | 1..* | Reference(Condición (IPS-CL)) | 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:sectionProcedimientos |
SC | 0..1 | BackboneElement | Historial de Procedimientos 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 | ||||
| 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) | |||||
| 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: 47519-4 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Procedure | DocumentReference) | Procedimientos anteriores del paciente pertinentes para el ámbito de este documento. Slice: Unordered, Open by profile:resolve() | ||||
| entry:procedimiento |
SC | 1..* | Reference(Procedure (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:sectionImmunizaciones |
SC | 0..1 | BackboneElement | Sección de Inmunizaciones 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 | ||||
| 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) | |||||
| 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: 11369-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Immunization | DocumentReference) | Estado de vacunación del paciente y antecedentes pertinentes. Slice: Unordered, Open by profile:resolve() | ||||
| entry:immunizacion |
SC | 1..* | Reference(Immunización (IPS-CL)) | 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:sectionDispMedicos |
SC | 0..1 | BackboneElement | Sección de Dispositivos Médicos 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 | ||||
| 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) | |||||
| 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: 46264-8 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | La historia de dispositivos médicos en uso Slice: Unordered, Open by profile:resolve() | ||||
| entry:deviceStatement |
SC | 1..* | Reference(Device Use Statement (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:sectionResultados |
SC | 0..1 | BackboneElement | Sección de Resultados 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 | ||||
| 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) | |||||
| 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: 30954-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
SC | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Resultados de observación relevantes recogidos en el paciente o producidos en muestras biológicas in vitro recogidas del paciente. Slice: Unordered, Open by type:resolve(), profile:resolve() | ||||
| entry:resultados-obs-lab-pato |
SC | 0..* | Reference(Observación Resultado: Laboratorio/Patología (IPS-CL)) | A reference to data that supports this section | ||||
| entry:resultados-obs-radio |
SC | 0..* | Reference(Observación Resultado: Imagenológico (IPS-CL)) | A reference to data that supports this section | ||||
| entry:resultado-reporte |
SC | 0..* | Reference(Reporte Diagnóstico (IPS-CL)) | 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:sectionSignosVitales |
C | 0..1 | BackboneElement | Sección de Signos Vitales 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 | ||||
| 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 |
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) | |||||
| 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: 8716-3 | |||||
| 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 |
C | 0..* | Reference(Observation | DocumentReference) | Signos vitales o hallazgos físicos de interés. Slice: Unordered, Open by profile:resolve() | ||||
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | 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:sectionHistoricoHx |
C | 0..1 | BackboneElement | Histórico de enfermedades 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 | ||||
| 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 |
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) | |||||
| 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: 11348-0 | |||||
| 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 |
C | 1..* | Reference(Condition | DocumentReference) | Condiciones sufridas por el paciente en el pasado Slice: Unordered, Open by profile:resolve() | ||||
| entry:pastProblem |
C | 1..* | Reference(Condición (IPS-CL)) | 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:sectionStatusFuncional |
C | 0..1 | BackboneElement | Status Funcional 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 | ||||
| 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 |
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) | |||||
| 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: 47420-5 | |||||
| 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 | |||||
| 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 |
C | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Entrada opcional utilizada para representar discapacidades y evaluaciones funcionales Slice: Unordered, Open by profile:resolve() | ||||
| entry:discapacidad |
C | 0..* | Reference(Condición (IPS-CL)) | A reference to data that supports this section | ||||
| entry:evalFuncional |
C | 0..* | Reference(ClinicalImpression) | 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:sectionPlanCuidado |
C | 0..1 | BackboneElement | Plan de Cuidado 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 | ||||
| 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 |
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) | |||||
| 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: 18776-5 | |||||
| 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 | |||||
| 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 |
C | 0..* | Reference(CarePlan | DocumentReference) | Resumen de plan de cuidados Slice: Unordered, Open by profile:resolve() | ||||
| entry:carePlan |
C | 0..* | Reference(CarePlan) | 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:sectionHistoriaSocial |
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 | ||||
| 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 |
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) | |||||
| 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: 29762-2 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry |
C | 0..* | Reference(Observation | DocumentReference) | Aspectos relacionados con salud "factores de estilo de vida" u "observaciones asociadas a estilos de vida" (e.j. Hábitos de fumar; consumo de alcohol; dietas, hábitos de riesgo.) Slice: Unordered, Open by profile:resolve() | ||||
| entry:fumador |
C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | ||||
| entry:alcohol |
C | 0..1 | Reference(Observation - SH: alcohol use) | 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:sectionEmbarazoHx |
C | 0..1 | BackboneElement | Historial de Embarazos 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 | ||||
| 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 |
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) | |||||
| 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: 10162-6 | |||||
| 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 |
C | 0..* | Reference(Observation | DocumentReference) | Estado actual del embarazo y, opcionalmente, información sobre el resultado de embarazos anteriores. Slice: Unordered, Open by profile:resolve() | ||||
| entry:statusEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | ||||
| entry:resultadoEmbarazo |
C | 0..* | Reference(Observation - Pregnancy: outcome) | 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:sectionDirectivasAvanzadas |
C | 0..1 | BackboneElement | Sección de Concentimientos 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 | ||||
| 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 |
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) | |||||
| 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: 42348-3 | |||||
| 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 |
C | 0..* | Reference(Consent | DocumentReference) | Descripción narrativa del documento de declaraciones de acceso del paciente. Slice: Unordered, Open by profile:resolve() | ||||
| entry:advanceDirectivesConsent |
C | 0..* | Reference(Consent) | 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | Pattern: LOINC Code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionMedicamentos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionAlergias.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionAlergias.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionProblemas.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionProblemas.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionProcedimientos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionImmunizaciones.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionDispMedicos.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionResultados.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionResultados.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionSignosVitales.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionHistoricoHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionStatusFuncional.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionPlanCuidado.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionHistoriaSocial.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionEmbarazoHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:sectionDirectivasAvanzadas.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:sectionMedicamentos, Composition.section:sectionAlergias, Composition.section:sectionProblemas, Composition.section:sectionProcedimientos, Composition.section:sectionImmunizaciones, Composition.section:sectionDispMedicos, Composition.section:sectionResultados, Composition.section:sectionSignosVitales, Composition.section:sectionHistoricoHx, Composition.section:sectionStatusFuncional, Composition.section:sectionPlanCuidado, Composition.section:sectionHistoriaSocial, Composition.section:sectionEmbarazoHx, Composition.section:sectionDirectivasAvanzadas | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 15 elements(21 nested mandatory elements)
Must-Support: 49 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron