Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva)
1.9.3 - draft
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
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:
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 | 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) |
subject | S | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | |
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar 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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | |
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | ||||
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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) |
subject | S | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | |
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar 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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | |
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard | ||||
Composition.type | preferred | VSTiposDocClinico (a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico from this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron