Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva)
1.9.3 - draft Chile flag

Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva), published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 1.9.3 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/clcore_ig/ and changes regularly. See the Directory of published versions

Resource Profile: CL Documento

Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl Version: 1.9.3
Active as of 2024-12-19 Computable Name: DocumentoCl

Copyright/Legal: Usado con el permiso de HL7 International, todos los derechos resevados en los Licencias de HL7 Internacional.

De un formato genérico para documento clínico en Chile.

Usage:

Formal Views of Profile Content

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

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... identifier S 0..1 Identifier Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
... status S 1..1 code Estado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type S 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... encounter S 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
... date S 1..1 dateTime Fecha en la cual se editó el documento
... author S 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
... title S 1..1 string Título del documento generado
... attester S 0..* BackboneElement Profesionales validadores del documento
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S 0..1 dateTime Fecha y Hora de la validación
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
... custodian S 0..1 Reference(CL Organización) Organización que mantiene los documentos
... section S 1..* BackboneElement Sección del documento
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text S 0..1 Narrative Texto que describe el contenido de la sección
.... entry S 0..* Reference(Resource) Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier SΣ 0..1 Identifier Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
ele-1: All FHIR elements must have a @value or children
... subject SΣ 0..1 Reference(Resource) Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
ele-1: All FHIR elements must have a @value or children
... encounter SΣ 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
ele-1: All FHIR elements must have a @value or children
... date SΣ 1..1 dateTime Fecha en la cual se editó el documento
ele-1: All FHIR elements must have a @value or children
... author SΣ 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
ele-1: All FHIR elements must have a @value or children
... title SΣ 1..1 string Título del documento generado
ele-1: All FHIR elements must have a @value or children
... attester S 0..* BackboneElement Profesionales validadores del documento
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR


ele-1: All FHIR elements must have a @value or children
.... time S 0..1 dateTime Fecha y Hora de la validación
ele-1: All FHIR elements must have a @value or children
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
ele-1: All FHIR elements must have a @value or children
... custodian SΣ 0..1 Reference(CL Organización) Organización que mantiene los documentos
ele-1: All FHIR elements must have a @value or children
... section SC 1..* BackboneElement Sección del documento
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
ele-1: All FHIR elements must have a @value or children
.... text SC 0..1 Narrative Texto que describe el contenido de la sección
ele-1: All FHIR elements must have a @value or children
.... entry SC 0..* Reference(Resource) Recurso referenciado en esta sección
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 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 Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
... status ?!SΣ 1..1 code Estado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type SΣ 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Resource) Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
... encounter SΣ 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
... date SΣ 1..1 dateTime Fecha en la cual se editó el documento
... author SΣ 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
... title SΣ 1..1 string Título del documento generado
... 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 Profesionales validadores del 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
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S 0..1 dateTime Fecha y Hora de la validación
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
... custodian SΣ 0..1 Reference(CL Organización) Organización que mantiene los documentos
... 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)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 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
... section SC 1..* BackboneElement Sección del documento
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 0..1 string Label for section (e.g. for ToC)
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... 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 0..1 Narrative Texto que describe el contenido de la sección
.... 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 SC 0..* Reference(Resource) Recurso referenciado en esta sección
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... identifier S 0..1 Identifier Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
... status S 1..1 code Estado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type S 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... encounter S 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
... date S 1..1 dateTime Fecha en la cual se editó el documento
... author S 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
... title S 1..1 string Título del documento generado
... attester S 0..* BackboneElement Profesionales validadores del documento
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S 0..1 dateTime Fecha y Hora de la validación
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
... custodian S 0..1 Reference(CL Organización) Organización que mantiene los documentos
... section S 1..* BackboneElement Sección del documento
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text S 0..1 Narrative Texto que describe el contenido de la sección
.... entry S 0..* Reference(Resource) Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier SΣ 0..1 Identifier Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
ele-1: All FHIR elements must have a @value or children
... subject SΣ 0..1 Reference(Resource) Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
ele-1: All FHIR elements must have a @value or children
... encounter SΣ 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
ele-1: All FHIR elements must have a @value or children
... date SΣ 1..1 dateTime Fecha en la cual se editó el documento
ele-1: All FHIR elements must have a @value or children
... author SΣ 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
ele-1: All FHIR elements must have a @value or children
... title SΣ 1..1 string Título del documento generado
ele-1: All FHIR elements must have a @value or children
... attester S 0..* BackboneElement Profesionales validadores del documento
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR


ele-1: All FHIR elements must have a @value or children
.... time S 0..1 dateTime Fecha y Hora de la validación
ele-1: All FHIR elements must have a @value or children
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
ele-1: All FHIR elements must have a @value or children
... custodian SΣ 0..1 Reference(CL Organización) Organización que mantiene los documentos
ele-1: All FHIR elements must have a @value or children
... section SC 1..* BackboneElement Sección del documento
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
ele-1: All FHIR elements must have a @value or children
.... text SC 0..1 Narrative Texto que describe el contenido de la sección
ele-1: All FHIR elements must have a @value or children
.... entry SC 0..* Reference(Resource) Recurso referenciado en esta sección
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 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 Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
... status ?!SΣ 1..1 code Estado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type SΣ 1..1 CodeableConcept Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Resource) Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
... encounter SΣ 0..1 Reference(CL Encuentro Clínico) Contexto asistencial en el cual se generó Documento.
... date SΣ 1..1 dateTime Fecha en la cual se editó el documento
... author SΣ 1..* Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) Quien Ha creado el documento
... title SΣ 1..1 string Título del documento generado
... 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 Profesionales validadores del 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
.... mode S 1..1 code Labor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S 0..1 dateTime Fecha y Hora de la validación
.... party S 0..1 Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) Quien validó
... custodian SΣ 0..1 Reference(CL Organización) Organización que mantiene los documentos
... 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)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 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
... section SC 1..* BackboneElement Sección del documento
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 0..1 string Label for section (e.g. for ToC)
.... code S 0..1 CodeableConcept Código que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... 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 0..1 Narrative Texto que describe el contenido de la sección
.... 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 SC 0..* Reference(Resource) Recurso referenciado en esta sección
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinico (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

 

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