PCC - mobile Paramedicine Summary of Care (mPSC)
2.0.0-draft - ci-build
PCC - mobile Paramedicine Summary of Care (mPSC)
2.0.0-draft - ci-build
PCC - mobile Paramedicine Summary of Care (mPSC), published by IHE Patient Care Coordination. This guide is not an authorized publication; it is the continuous build for version 2.0.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/PCC.PCS/ and changes regularly. See the Directory of published versions
| Official URL: https://profiles.ihe.net/PCC/mPSC/StructureDefinition/IHE.PCC.mPSC.Composition.ClinicalSubset | Version: 2.0.0-draft | |||
| Draft as of 2025-03-04 | Computable Name: IHE_PCC_mPSC_Composition_ClinicalSubset | |||
The composition of the FHIR elements that are used to build the FHIR Document for the Paramedicine Care Summary Clinical Subset the following cardinalities follow the documentation in the PCS profile:
O 0..1 Payor
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  language |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
 Slices for extension |
Content/Rules for all slices | |||
   extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension |
| identifier |
S | 1..1 | Identifier | Version-independent identifier for the Composition |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
| Slices for category |
S | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this |
| category:pstat |
1..1 | CodeableConcept | Categorization of 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: 34133-9 | |
 subject |
S | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title |
S | 1..1 | string | Human Readable name/title |
| confidentiality |
1..1 | code | As defined by affinity domain | |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition |
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian |
S | 0..1 | Reference(Organization) | Organization which maintains the composition |
| Slices for event |
1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |
| event:careProvisioningEvent |
S | 0..1 | BackboneElement | The clinical service(s) being documented |
 code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented |
| period |
S | 0..1 | Period | The period covered by the documentation |
| Slices for section |
7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
 section:All Slices |
Content/Rules for all slices | |||
 code |
S | 1..1 | CodeableConcept | Classification of section (recommended) |
| text |
S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:sectionDetailedChiefComplaint |
S | 1..1 | BackboneElement | Chief Complaint Section |
| code |
1..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: 10154-3 | |
| Slices for entry |
0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference | |
| entry:chiefComplaintObservations |
S | 0..* | Reference(Observation) | A reference to data that supports this section |
| entry:chiefComplaint |
0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionCodedReasonforVisit |
S | 1..1 | BackboneElement | section Reason for Visit Section |
| code |
1..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: 29299-5 | |
| entry |
S | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionPresentIllnessHx |
S | 1..1 | BackboneElement | IHE History of Present Illness Section |
| code |
1..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: 10164-2 | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionProblems |
S | 1..1 | BackboneElement | IHE Active Problems Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry |
S | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
| entry:problem |
0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionMedications |
S | 1..1 | BackboneElement | IHE Medications section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry |
S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
| entry:medicationStatement |
0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
| entry:medicationRequest |
0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | |
| section:sectionAllergies |
S | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry |
S | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
| entry:allergyOrIntolerance |
0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | |
| section:sectionPastIllnessHx |
S | 0..1 | BackboneElement | IHE History of Past Illness Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry |
0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference | |
| entry:pastProblem |
0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| section:sectionProceduresHx |
S | 0..1 | BackboneElement | History of Procedures Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry |
S | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
| entry:procedure |
0..* | Reference(Procedure (IPS)) | A reference to data that supports this section | |
| section:sectionImmunizations |
S | 0..1 | BackboneElement | IHE Immunizations Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry |
S | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
| entry:immunization |
0..* | Reference(Immunization (IPS)) | A reference to data that supports this section | |
| entry:immunizationAdministration |
0..* | Reference(MedicationAdministration) | A reference to data that supports this section | |
| section:sectionSocialHistory |
S | 0..1 | BackboneElement | IHE Social History Section |
| code |
1..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) | Social History Entry Slice: Unordered, Open by pattern:reference | |
| entry:smokingTobaccoUse |
0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
| entry:alcoholUse |
0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
| entry:employment |
0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this section | |
| section:sectionReviewOfSystems |
S | 0..1 | BackboneElement | IHE Review of Systems Section |
| code |
1..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: 10187-3 | |
| section:sectionVitalSigns |
S | 0..1 | BackboneElement | Vital Signs Section |
| code |
1..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 |
S | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
| entry:vitalSign |
0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
| section:sectionMedicalDevices |
S | 0..1 | BackboneElement | Medical Devices Section |
| code |
1..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) | medical device use Slice: Unordered, Open by pattern:reference |
| entry:deviceStatement |
1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this section | |
| section:sectionCodedDetailPhysicalExamination |
S | 0..1 | BackboneElement | IHE Physical Examination Section |
| code |
1..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: 29545-1 | |
| entry |
S | 0..* | Reference(Observation | DocumentReference) | Physical findings |
| Slices for section |
2..* | Nested Section Slice: Unordered, Open by pattern:code | ||
| section:respiratorySystem |
1..1 | BackboneElement | Respiratory System Exam | |
| code |
1..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: 11412-4 | |
| entry |
S | 0..* | Reference(Observation) | Physical findings of the respiratory system exam |
| section:heart |
1..1 | BackboneElement | Heart Exam | |
| code |
1..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: 10200-4 | |
| entry |
S | 0..* | Reference(Observation) | Physical findings of the heart exam |
| section:sectionResults |
S | 0..1 | BackboneElement | IHE Results Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry |
S | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
| entry:results-observation |
0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section | |
| entry:results-diagnosticReport |
0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section | |
| section:sectionCarePlan |
S | 0..1 | BackboneElement | IHE Care Plan Section |
| code |
1..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 |
S | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
| entry:carePlan |
0..* | Reference(CarePlan) | A reference to data that supports this section | |
| section:sectionAdvancedirectives |
S | 0..1 | BackboneElement | IHE Advance directives section |
| code |
1..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 |
1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference | |
| entry:advanceDirectivesConsent |
1..1 | Reference(Consent) | A reference to data that supports this section | |
| section:sectionFunctionalStatus |
S | 0..1 | BackboneElement | Functional Status |
| code |
1..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 |
S | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
| entry:disability |
0..* | Reference(Condition) | A reference to data that supports this section | |
| entry:functionalAssessment |
0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
| section:sectionPayers |
0..1 | BackboneElement | Payers Section | |
| code |
1..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: 48768-6 | |
| Slices for entry |
S | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
| entry:coverage |
0..* | Reference(Coverage) | A reference to data that supports this section | |
| section:sectionIncident |
S | 0..1 | BackboneElement | Incident Section |
| code |
1..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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
| Slices for entry |
S | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
| entry:incidentEvent |
0..1 | Reference(Incident) | A reference to data that supports this section | |
| entry:numberOfAffectedPeople |
0..1 | Reference(Number of Affected People) | A reference to data that supports this section | |
| entry:MassCasualtyIncidentIndicator |
0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section | |
| entry:possibleInjury |
0..1 | Reference(Possible Injury) | A reference to data that supports this section | |
| section:sectionTreatment |
0..1 | BackboneElement | Treatment Section | |
| code |
1..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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
| Slices for entry |
S | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
| entry:barriersToCare |
0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section | |
| Slices for section |
0..* | Nested Section Slice: Unordered, Open by pattern:code | ||
| section:proceduresPerformed |
S | 0..* | BackboneElement | IHE Procedures and Interventions Section |
| code |
1..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: 29554-3 | |
| entry |
S | 0..* | Reference(Procedure | DocumentReference) | Procedure Entry |
| section:medicationsAdministered |
S | 0..* | BackboneElement | IHE Medications Administered Section |
| code |
1..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: 18610-6 | |
| entry |
S | 0..* | Reference(MedicationAdministration | DocumentReference) | Medications Administered |
| section:sectionTriage |
0..1 | BackboneElement | Triage section | |
| code |
1..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: 11283-9 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| section:sectionInjuryIncidentDescription |
0..1 | BackboneElement | Injury section | |
| code |
1..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: 11374-6 | |
| Slices for entry |
S | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
| entry:patientActivity |
0..1 | Reference(Patient Activity) | A reference to data that supports this section | |
| entry:injuryCause |
0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
| entry:injuryMechanism |
0..* | Reference(Mechanism of Injury) | A reference to data that supports this section | |
| entry:heightOfFall |
0..1 | Reference(Height of Fall) | A reference to data that supports this section | |
| entry:protectiveEquipmentUsed |
0..* | Reference(Protective Equipment Used) | A reference to data that supports this section | |
| entry:safetyEquipmentUsed |
0..* | Reference(Safety Equipment Used) | A reference to data that supports this section | |
| entry:collissionData |
0..* | Reference(Collision Data) | A reference to data that supports this section | |
| entry:workPlaceInjuryIndicator |
0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section | |
| section:sectionAssessments |
1..1 | BackboneElement | Assessments | |
| code |
1..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: 51848-0 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| section:sectionPregnancyHistory |
S | 0..1 | BackboneElement | Pregnancy History |
| code |
1..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 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
| section:sectionCardiacArrestEvent |
0..1 | BackboneElement | Cardiac Arrest Event | |
| code |
1..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: 67799-7 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
| section:sectionProviderOrders |
0..1 | BackboneElement | Provider Orders | |
| code |
1..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: 46209-3 | |
| entry |
S | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | 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 |
| language |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) ele-1: All FHIR elements must have a @value or children |
 text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| extension:versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
 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 | 1..1 | Identifier | Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children |
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children |
| category:pstat |
Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children 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: 34133-9 | |
| subject |
SΣ | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
| date |
SΣ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children |
| title |
SΣ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children |
| confidentiality |
Σ | 1..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. ele-1: All FHIR elements must have a @value or children |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition 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 | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children |
| time |
S | 0..1 | dateTime | When the composition was attested ele-1: All FHIR elements must have a @value or children |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition ele-1: All FHIR elements must have a @value or children |
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children |
| Slices for event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children |
| event:All Slices |
Content/Rules for all slices | |||
| 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 |
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The clinical service(s) being documented 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 |
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. ele-1: All FHIR elements must have a @value or children |
| period |
SΣ | 0..1 | Period | The period covered by the documentation ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 7..* | BackboneElement | Composition is broken into sections 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 ele-1: All FHIR elements must have a @value or children |
| section:All Slices |
Content/Rules for all slices | |||
| 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| section:sectionDetailedChiefComplaint |
SC | 1..1 | BackboneElement | Chief Complaint 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10154-3 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:chiefComplaintObservations |
SC | 0..* | Reference(Observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:chiefComplaint |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionCodedReasonforVisit |
SC | 1..1 | BackboneElement | section Reason for Visit 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29299-5 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionPresentIllnessHx |
SC | 1..1 | BackboneElement | IHE History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10164-2 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionProblems |
SC | 1..1 | BackboneElement | IHE Active Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:problem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionMedications |
SC | 1..1 | BackboneElement | IHE Medications 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:medicationStatement |
C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:medicationRequest |
C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAllergies |
SC | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:allergyOrIntolerance |
C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPastIllnessHx |
SC | 0..1 | BackboneElement | IHE History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:pastProblem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionProceduresHx |
SC | 0..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:procedure |
C | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionImmunizations |
SC | 0..1 | BackboneElement | IHE Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:immunization |
C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:immunizationAdministration |
C | 0..* | Reference(MedicationAdministration) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionSocialHistory |
SC | 0..1 | BackboneElement | IHE 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:smokingTobaccoUse |
C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:alcoholUse |
C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:employment |
C | 0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionReviewOfSystems |
SC | 0..1 | BackboneElement | IHE Review of Systems 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10187-3 | |
| section:sectionVitalSigns |
SC | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionMedicalDevices |
SC | 0..1 | BackboneElement | Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:deviceStatement |
C | 1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionCodedDetailPhysicalExamination |
SC | 0..1 | BackboneElement | IHE Physical Examination 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29545-1 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..* | Reference(Observation | DocumentReference) | Physical findings ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 2..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code ele-1: All FHIR elements must have a @value or children |
| section:respiratorySystem |
C | 1..1 | BackboneElement | Respiratory System Exam 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11412-4 | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the respiratory system exam ele-1: All FHIR elements must have a @value or children |
| section:heart |
C | 1..1 | BackboneElement | Heart Exam 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10200-4 | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the heart exam ele-1: All FHIR elements must have a @value or children |
| section:sectionResults |
SC | 0..1 | BackboneElement | IHE Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:results-observation |
C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:results-diagnosticReport |
C | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionCarePlan |
SC | 0..1 | BackboneElement | IHE Care Plan 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:carePlan |
C | 0..* | Reference(CarePlan) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAdvancedirectives |
SC | 0..1 | BackboneElement | IHE Advance directives section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:advanceDirectivesConsent |
C | 1..1 | Reference(Consent) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionFunctionalStatus |
SC | 0..1 | BackboneElement | Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:disability |
C | 0..* | Reference(Condition) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:functionalAssessment |
C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPayers |
C | 0..1 | BackboneElement | Payers 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 48768-6 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:coverage |
C | 0..* | Reference(Coverage) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionIncident |
SC | 0..1 | BackboneElement | Incident 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:incidentEvent |
C | 0..1 | Reference(Incident) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:numberOfAffectedPeople |
C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:MassCasualtyIncidentIndicator |
C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:possibleInjury |
C | 0..1 | Reference(Possible Injury) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionTreatment |
C | 0..1 | BackboneElement | Treatment 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:barriersToCare |
C | 0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 0..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code ele-1: All FHIR elements must have a @value or children |
| section:proceduresPerformed |
SC | 0..* | BackboneElement | IHE Procedures and Interventions Section 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29554-3 | |
| entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Procedure Entry ele-1: All FHIR elements must have a @value or children |
| section:medicationsAdministered |
SC | 0..* | BackboneElement | IHE Medications Administered Section 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 18610-6 | |
| entry |
SC | 0..* | Reference(MedicationAdministration | DocumentReference) | Medications Administered ele-1: All FHIR elements must have a @value or children |
| section:sectionTriage |
C | 0..1 | BackboneElement | Triage 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11283-9 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment ele-1: All FHIR elements must have a @value or children |
| section:sectionInjuryIncidentDescription |
C | 0..1 | BackboneElement | Injury 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11374-6 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:patientActivity |
C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:injuryCause |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:injuryMechanism |
C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:heightOfFall |
C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:protectiveEquipmentUsed |
C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:safetyEquipmentUsed |
C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:collissionData |
C | 0..* | Reference(Collision Data) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:workPlaceInjuryIndicator |
C | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAssessments |
C | 1..1 | BackboneElement | Assessments 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 51848-0 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment ele-1: All FHIR elements must have a @value or children |
| section:sectionPregnancyHistory |
SC | 0..1 | BackboneElement | Pregnancy History 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations ele-1: All FHIR elements must have a @value or children |
| section:sectionCardiacArrestEvent |
C | 0..1 | BackboneElement | Cardiac Arrest Event 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 67799-7 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations ele-1: All FHIR elements must have a @value or children |
| section:sectionProviderOrders |
C | 0..1 | BackboneElement | Provider Orders 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 46209-3 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.language | preferred | CommonLanguageshttp://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 | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | |
| Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodesfrom 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.event:careProvisioningEvent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | 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 |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained |
0..* | Resource | Contained, inline Resources | |
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
SΣ | 1..1 | Identifier | Version-independent identifier for the Composition |
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| category:pstat |
Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 34133-9 | |
| 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 | |
| subject |
SΣ | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about |
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title |
SΣ | 1..1 | string | Human Readable name/title |
| confidentiality |
Σ | 1..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) | |||
| Slices for event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code |
| event:All Slices |
Content/Rules for all slices | |||
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period |
Σ | 0..1 | Period | The period covered by the documentation |
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented |
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The 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 |
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. |
| period |
SΣ | 0..1 | Period | The period covered by the documentation |
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section |
C | 7..* | BackboneElement | Composition is broken into sections 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 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section |
C | 0..* | See section (Composition) | Nested Section |
| section:sectionDetailedChiefComplaint |
SC | 1..1 | BackboneElement | Chief Complaint 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 10154-3 | |
| 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 |
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. | |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference |
| entry:chiefComplaintObservations |
SC | 0..* | Reference(Observation) | A reference to data that supports this section |
| entry:chiefComplaint |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| emptyReason |
SC | 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:sectionCodedReasonforVisit |
SC | 1..1 | BackboneElement | section Reason for Visit 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 29299-5 | |
| 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 |
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 |
SC | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section |
| emptyReason |
SC | 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:sectionPresentIllnessHx |
SC | 1..1 | BackboneElement | IHE History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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: 10164-2 | |
| 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 |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason |
SC | 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:sectionProblems |
SC | 1..1 | BackboneElement | IHE Active Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
| entry:problem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| emptyReason |
SC | 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:sectionMedications |
SC | 1..1 | BackboneElement | IHE Medications 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
| entry:medicationStatement |
C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
| entry:medicationRequest |
C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section |
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section |
C | 0..* | See section (Composition) | Nested Section |
| section:sectionAllergies |
SC | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
| entry:allergyOrIntolerance |
C | 0..* | Reference(Allergy Intolerance (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:sectionPastIllnessHx |
SC | 0..1 | BackboneElement | IHE History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference |
| entry:pastProblem |
C | 0..* | Reference(Condition (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:sectionProceduresHx |
SC | 0..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
| entry:procedure |
C | 0..* | 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:sectionImmunizations |
SC | 0..1 | BackboneElement | IHE Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
| entry:immunization |
C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| entry:immunizationAdministration |
C | 0..* | Reference(MedicationAdministration) | 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:sectionSocialHistory |
SC | 0..1 | BackboneElement | IHE 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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 |
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. | |
| Slices for entry |
C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference |
| entry:smokingTobaccoUse |
C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
| entry:alcoholUse |
C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
| entry:employment |
C | 0..* | Reference(Employment Status | Usual Work) | 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:sectionReviewOfSystems |
SC | 0..1 | BackboneElement | IHE Review of Systems 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 10187-3 | |
| 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. | |
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section |
C | 0..* | See section (Composition) | Nested Section |
| section:sectionVitalSigns |
SC | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
| 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:sectionMedicalDevices |
SC | 0..1 | BackboneElement | Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
| entry:deviceStatement |
C | 1..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:sectionCodedDetailPhysicalExamination |
SC | 0..1 | BackboneElement | IHE Physical Examination 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 29545-1 | |
| 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 |
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 |
SC | 0..* | Reference(Observation | DocumentReference) | Physical findings |
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| Slices for section |
C | 2..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code |
| section:respiratorySystem |
C | 1..1 | BackboneElement | Respiratory System Exam |
| 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 |
1..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: 11412-4 | |
| 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. | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the respiratory system exam |
| 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:heart |
C | 1..1 | BackboneElement | Heart Exam |
| 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 |
1..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: 10200-4 | |
| 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. | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the heart exam |
| 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:sectionResults |
SC | 0..1 | BackboneElement | IHE Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
| entry:results-observation |
C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
| entry:results-diagnosticReport |
C | 0..* | Reference(DiagnosticReport (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:sectionCarePlan |
SC | 0..1 | BackboneElement | IHE Care Plan 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
| 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:sectionAdvancedirectives |
SC | 0..1 | BackboneElement | IHE Advance directives section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference |
| entry:advanceDirectivesConsent |
C | 1..1 | 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 |
| section:sectionFunctionalStatus |
SC | 0..1 | BackboneElement | Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| 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 | 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
| entry:disability |
C | 0..* | Reference(Condition) | A reference to data that supports this section |
| entry:functionalAssessment |
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:sectionPayers |
C | 0..1 | BackboneElement | Payers 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 48768-6 | |
| 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
| entry:coverage |
C | 0..* | Reference(Coverage) | 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:sectionIncident |
SC | 0..1 | BackboneElement | Incident 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
| 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
| entry:incidentEvent |
C | 0..1 | Reference(Incident) | A reference to data that supports this section |
| entry:numberOfAffectedPeople |
C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section |
| entry:MassCasualtyIncidentIndicator |
C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section |
| entry:possibleInjury |
C | 0..1 | Reference(Possible Injury) | 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:sectionTreatment |
C | 0..1 | BackboneElement | Treatment 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
| 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 |
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. | |
| Slices for entry |
SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
| entry:barriersToCare |
C | 0..1 | Reference(IHE barriers to care observation) | 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. |
| Slices for section |
C | 0..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code |
| section:proceduresPerformed |
SC | 0..* | BackboneElement | IHE Procedures and Interventions Section |
| 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 |
1..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: 29554-3 | |
| 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. | |
| entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Procedure Entry |
| 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:medicationsAdministered |
SC | 0..* | BackboneElement | IHE Medications Administered Section |
| 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 |
1..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: 18610-6 | |
| 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. | |
| entry |
SC | 0..* | Reference(MedicationAdministration | DocumentReference) | Medications Administered |
| 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:sectionTriage |
C | 0..1 | BackboneElement | Triage 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 11283-9 | |
| 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 |
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 |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| 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:sectionInjuryIncidentDescription |
C | 0..1 | BackboneElement | Injury 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 |
0..1 | string | Label for section (e.g. for ToC) | |
| code |
S | 1..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: 11374-6 | |
| 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 |
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. | |
| Slices for entry |
SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
| entry:patientActivity |
C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section |
| entry:injuryCause |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| entry:injuryMechanism |
C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section |
| entry:heightOfFall |
C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section |
| entry:protectiveEquipmentUsed |
C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section |
| entry:safetyEquipmentUsed |
C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section |
| entry:collissionData |
C | 0..* | Reference(Collision Data) | A reference to data that supports this section |
| entry:workPlaceInjuryIndicator |
C | 0..* | Reference(Work Place Injury Indicator) | 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:sectionAssessments |
C | 1..1 | BackboneElement | Assessments 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 | 1..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: 51848-0 | |
| 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 |
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 |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| 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:sectionPregnancyHistory |
SC | 0..1 | BackboneElement | Pregnancy History 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 | 1..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 |
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 |
SC | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
| 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:sectionCardiacArrestEvent |
C | 0..1 | BackboneElement | Cardiac Arrest Event 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 | 1..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: 67799-7 | |
| 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 |
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 |
SC | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
| 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:sectionProviderOrders |
C | 0..1 | BackboneElement | Provider Orders 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 | 1..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: 46209-3 | |
| 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 |
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 |
SC | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders |
| 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 | CommonLanguageshttp://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 | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | |
| Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodesfrom 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 | ActCodehttp://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.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProblems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionMedicalDevices.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCarePlan.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCarePlan.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCarePlan.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPayers.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionPayers.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionPayers.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionIncident.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionIncident.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionIncident.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionTreatment.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionTreatment.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTriage.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionTriage.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionTriage.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAssessments.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionAssessments.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionAssessments.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProviderOrders.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | |
| Composition.section:sectionProviderOrders.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | |
| Composition.section:sectionProviderOrders.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
This structure is derived from Clinical Document
Summary
Mandatory: 16 elements(12 nested mandatory elements)
Must-Support: 72 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| language |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| Slices for extension |
Content/Rules for all slices | |||
| extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension |
| identifier |
S | 1..1 | Identifier | Version-independent identifier for the Composition |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
| Slices for category |
S | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this |
| category:pstat |
1..1 | CodeableConcept | Categorization of 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: 34133-9 | |
| subject |
S | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title |
S | 1..1 | string | Human Readable name/title |
| confidentiality |
1..1 | code | As defined by affinity domain | |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition |
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian |
S | 0..1 | Reference(Organization) | Organization which maintains the composition |
| Slices for event |
1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |
| event:careProvisioningEvent |
S | 0..1 | BackboneElement | The clinical service(s) being documented |
| code |
S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented |
| period |
S | 0..1 | Period | The period covered by the documentation |
| Slices for section |
7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
| section:All Slices |
Content/Rules for all slices | |||
| code |
S | 1..1 | CodeableConcept | Classification of section (recommended) |
| text |
S | 1..1 | Narrative | Text summary of the section, for human interpretation |
| section:sectionDetailedChiefComplaint |
S | 1..1 | BackboneElement | Chief Complaint Section |
| code |
1..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: 10154-3 | |
| Slices for entry |
0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference | |
| entry:chiefComplaintObservations |
S | 0..* | Reference(Observation) | A reference to data that supports this section |
| entry:chiefComplaint |
0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionCodedReasonforVisit |
S | 1..1 | BackboneElement | section Reason for Visit Section |
| code |
1..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: 29299-5 | |
| entry |
S | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionPresentIllnessHx |
S | 1..1 | BackboneElement | IHE History of Present Illness Section |
| code |
1..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: 10164-2 | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionProblems |
S | 1..1 | BackboneElement | IHE Active Problems Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| Slices for entry |
S | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
| entry:problem |
0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| emptyReason |
S | 0..1 | CodeableConcept | Why the section is empty |
| section:sectionMedications |
S | 1..1 | BackboneElement | IHE Medications section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| Slices for entry |
S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
| entry:medicationStatement |
0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
| entry:medicationRequest |
0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | |
| section:sectionAllergies |
S | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| Slices for entry |
S | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
| entry:allergyOrIntolerance |
0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | |
| section:sectionPastIllnessHx |
S | 0..1 | BackboneElement | IHE History of Past Illness Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| Slices for entry |
0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference | |
| entry:pastProblem |
0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
| section:sectionProceduresHx |
S | 0..1 | BackboneElement | History of Procedures Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| Slices for entry |
S | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
| entry:procedure |
0..* | Reference(Procedure (IPS)) | A reference to data that supports this section | |
| section:sectionImmunizations |
S | 0..1 | BackboneElement | IHE Immunizations Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
| Slices for entry |
S | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
| entry:immunization |
0..* | Reference(Immunization (IPS)) | A reference to data that supports this section | |
| entry:immunizationAdministration |
0..* | Reference(MedicationAdministration) | A reference to data that supports this section | |
| section:sectionSocialHistory |
S | 0..1 | BackboneElement | IHE Social History Section |
| code |
1..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) | Social History Entry Slice: Unordered, Open by pattern:reference | |
| entry:smokingTobaccoUse |
0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
| entry:alcoholUse |
0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
| entry:employment |
0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this section | |
| section:sectionReviewOfSystems |
S | 0..1 | BackboneElement | IHE Review of Systems Section |
| code |
1..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: 10187-3 | |
| section:sectionVitalSigns |
S | 0..1 | BackboneElement | Vital Signs Section |
| code |
1..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 |
S | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
| entry:vitalSign |
0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
| section:sectionMedicalDevices |
S | 0..1 | BackboneElement | Medical Devices Section |
| code |
1..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) | medical device use Slice: Unordered, Open by pattern:reference |
| entry:deviceStatement |
1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this section | |
| section:sectionCodedDetailPhysicalExamination |
S | 0..1 | BackboneElement | IHE Physical Examination Section |
| code |
1..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: 29545-1 | |
| entry |
S | 0..* | Reference(Observation | DocumentReference) | Physical findings |
| Slices for section |
2..* | Nested Section Slice: Unordered, Open by pattern:code | ||
| section:respiratorySystem |
1..1 | BackboneElement | Respiratory System Exam | |
| code |
1..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: 11412-4 | |
| entry |
S | 0..* | Reference(Observation) | Physical findings of the respiratory system exam |
| section:heart |
1..1 | BackboneElement | Heart Exam | |
| code |
1..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: 10200-4 | |
| entry |
S | 0..* | Reference(Observation) | Physical findings of the heart exam |
| section:sectionResults |
S | 0..1 | BackboneElement | IHE Results Section |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| Slices for entry |
S | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
| entry:results-observation |
0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section | |
| entry:results-diagnosticReport |
0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section | |
| section:sectionCarePlan |
S | 0..1 | BackboneElement | IHE Care Plan Section |
| code |
1..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 |
S | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
| entry:carePlan |
0..* | Reference(CarePlan) | A reference to data that supports this section | |
| section:sectionAdvancedirectives |
S | 0..1 | BackboneElement | IHE Advance directives section |
| code |
1..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 |
1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference | |
| entry:advanceDirectivesConsent |
1..1 | Reference(Consent) | A reference to data that supports this section | |
| section:sectionFunctionalStatus |
S | 0..1 | BackboneElement | Functional Status |
| code |
1..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 |
S | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
| entry:disability |
0..* | Reference(Condition) | A reference to data that supports this section | |
| entry:functionalAssessment |
0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
| section:sectionPayers |
0..1 | BackboneElement | Payers Section | |
| code |
1..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: 48768-6 | |
| Slices for entry |
S | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
| entry:coverage |
0..* | Reference(Coverage) | A reference to data that supports this section | |
| section:sectionIncident |
S | 0..1 | BackboneElement | Incident Section |
| code |
1..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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
| Slices for entry |
S | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
| entry:incidentEvent |
0..1 | Reference(Incident) | A reference to data that supports this section | |
| entry:numberOfAffectedPeople |
0..1 | Reference(Number of Affected People) | A reference to data that supports this section | |
| entry:MassCasualtyIncidentIndicator |
0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section | |
| entry:possibleInjury |
0..1 | Reference(Possible Injury) | A reference to data that supports this section | |
| section:sectionTreatment |
0..1 | BackboneElement | Treatment Section | |
| code |
1..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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
| Slices for entry |
S | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
| entry:barriersToCare |
0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section | |
| Slices for section |
0..* | Nested Section Slice: Unordered, Open by pattern:code | ||
| section:proceduresPerformed |
S | 0..* | BackboneElement | IHE Procedures and Interventions Section |
| code |
1..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: 29554-3 | |
| entry |
S | 0..* | Reference(Procedure | DocumentReference) | Procedure Entry |
| section:medicationsAdministered |
S | 0..* | BackboneElement | IHE Medications Administered Section |
| code |
1..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: 18610-6 | |
| entry |
S | 0..* | Reference(MedicationAdministration | DocumentReference) | Medications Administered |
| section:sectionTriage |
0..1 | BackboneElement | Triage section | |
| code |
1..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: 11283-9 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| section:sectionInjuryIncidentDescription |
0..1 | BackboneElement | Injury section | |
| code |
1..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: 11374-6 | |
| Slices for entry |
S | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
| entry:patientActivity |
0..1 | Reference(Patient Activity) | A reference to data that supports this section | |
| entry:injuryCause |
0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
| entry:injuryMechanism |
0..* | Reference(Mechanism of Injury) | A reference to data that supports this section | |
| entry:heightOfFall |
0..1 | Reference(Height of Fall) | A reference to data that supports this section | |
| entry:protectiveEquipmentUsed |
0..* | Reference(Protective Equipment Used) | A reference to data that supports this section | |
| entry:safetyEquipmentUsed |
0..* | Reference(Safety Equipment Used) | A reference to data that supports this section | |
| entry:collissionData |
0..* | Reference(Collision Data) | A reference to data that supports this section | |
| entry:workPlaceInjuryIndicator |
0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section | |
| section:sectionAssessments |
1..1 | BackboneElement | Assessments | |
| code |
1..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: 51848-0 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
| section:sectionPregnancyHistory |
S | 0..1 | BackboneElement | Pregnancy History |
| code |
1..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 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
| section:sectionCardiacArrestEvent |
0..1 | BackboneElement | Cardiac Arrest Event | |
| code |
1..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: 67799-7 | |
| entry |
S | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
| section:sectionProviderOrders |
0..1 | BackboneElement | Provider Orders | |
| code |
1..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: 46209-3 | |
| entry |
S | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | 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 |
| language |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) ele-1: All FHIR elements must have a @value or children |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
Content/Rules for all slices | |||
| extension:versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| 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 | 1..1 | Identifier | Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children |
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children |
| category:pstat |
Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children 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: 34133-9 | |
| subject |
SΣ | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
| date |
SΣ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children |
| title |
SΣ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children |
| confidentiality |
Σ | 1..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. ele-1: All FHIR elements must have a @value or children |
| attester |
S | 0..* | BackboneElement | Attests to accuracy of composition 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 | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children |
| time |
S | 0..1 | dateTime | When the composition was attested ele-1: All FHIR elements must have a @value or children |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition ele-1: All FHIR elements must have a @value or children |
| custodian |
SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children |
| Slices for event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children |
| event:All Slices |
Content/Rules for all slices | |||
| 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 |
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The clinical service(s) being documented 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 |
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. ele-1: All FHIR elements must have a @value or children |
| period |
SΣ | 0..1 | Period | The period covered by the documentation ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 7..* | BackboneElement | Composition is broken into sections 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 ele-1: All FHIR elements must have a @value or children |
| section:All Slices |
Content/Rules for all slices | |||
| 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| section:sectionDetailedChiefComplaint |
SC | 1..1 | BackboneElement | Chief Complaint 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10154-3 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:chiefComplaintObservations |
SC | 0..* | Reference(Observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:chiefComplaint |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionCodedReasonforVisit |
SC | 1..1 | BackboneElement | section Reason for Visit 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29299-5 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionPresentIllnessHx |
SC | 1..1 | BackboneElement | IHE History of Present Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10164-2 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionProblems |
SC | 1..1 | BackboneElement | IHE Active Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:problem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| emptyReason |
SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children |
| section:sectionMedications |
SC | 1..1 | BackboneElement | IHE Medications 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:medicationStatement |
C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:medicationRequest |
C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAllergies |
SC | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:allergyOrIntolerance |
C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPastIllnessHx |
SC | 0..1 | BackboneElement | IHE History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:pastProblem |
C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionProceduresHx |
SC | 0..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:procedure |
C | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionImmunizations |
SC | 0..1 | BackboneElement | IHE Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:immunization |
C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:immunizationAdministration |
C | 0..* | Reference(MedicationAdministration) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionSocialHistory |
SC | 0..1 | BackboneElement | IHE 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:smokingTobaccoUse |
C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:alcoholUse |
C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:employment |
C | 0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionReviewOfSystems |
SC | 0..1 | BackboneElement | IHE Review of Systems 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10187-3 | |
| section:sectionVitalSigns |
SC | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:vitalSign |
C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionMedicalDevices |
SC | 0..1 | BackboneElement | Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:deviceStatement |
C | 1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionCodedDetailPhysicalExamination |
SC | 0..1 | BackboneElement | IHE Physical Examination 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29545-1 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..* | Reference(Observation | DocumentReference) | Physical findings ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 2..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code ele-1: All FHIR elements must have a @value or children |
| section:respiratorySystem |
C | 1..1 | BackboneElement | Respiratory System Exam 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11412-4 | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the respiratory system exam ele-1: All FHIR elements must have a @value or children |
| section:heart |
C | 1..1 | BackboneElement | Heart Exam 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 10200-4 | |
| entry |
SC | 0..* | Reference(Observation) | Physical findings of the heart exam ele-1: All FHIR elements must have a @value or children |
| section:sectionResults |
SC | 0..1 | BackboneElement | IHE Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:results-observation |
C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:results-diagnosticReport |
C | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionCarePlan |
SC | 0..1 | BackboneElement | IHE Care Plan 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:carePlan |
C | 0..* | Reference(CarePlan) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAdvancedirectives |
SC | 0..1 | BackboneElement | IHE Advance directives section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:advanceDirectivesConsent |
C | 1..1 | Reference(Consent) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionFunctionalStatus |
SC | 0..1 | BackboneElement | Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:disability |
C | 0..* | Reference(Condition) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:functionalAssessment |
C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionPayers |
C | 0..1 | BackboneElement | Payers 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 48768-6 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:coverage |
C | 0..* | Reference(Coverage) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionIncident |
SC | 0..1 | BackboneElement | Incident 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:incidentEvent |
C | 0..1 | Reference(Incident) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:numberOfAffectedPeople |
C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:MassCasualtyIncidentIndicator |
C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:possibleInjury |
C | 0..1 | Reference(Possible Injury) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionTreatment |
C | 0..1 | BackboneElement | Treatment 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:barriersToCare |
C | 0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| Slices for section |
C | 0..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code ele-1: All FHIR elements must have a @value or children |
| section:proceduresPerformed |
SC | 0..* | BackboneElement | IHE Procedures and Interventions Section 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 29554-3 | |
| entry |
SC | 0..* | Reference(Procedure | DocumentReference) | Procedure Entry ele-1: All FHIR elements must have a @value or children |
| section:medicationsAdministered |
SC | 0..* | BackboneElement | IHE Medications Administered Section 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 |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 18610-6 | |
| entry |
SC | 0..* | Reference(MedicationAdministration | DocumentReference) | Medications Administered ele-1: All FHIR elements must have a @value or children |
| section:sectionTriage |
C | 0..1 | BackboneElement | Triage 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11283-9 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment ele-1: All FHIR elements must have a @value or children |
| section:sectionInjuryIncidentDescription |
C | 0..1 | BackboneElement | Injury 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 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 11374-6 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| Slices for entry |
SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference ele-1: All FHIR elements must have a @value or children |
| entry:patientActivity |
C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:injuryCause |
C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:injuryMechanism |
C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:heightOfFall |
C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:protectiveEquipmentUsed |
C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:safetyEquipmentUsed |
C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:collissionData |
C | 0..* | Reference(Collision Data) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| entry:workPlaceInjuryIndicator |
C | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section ele-1: All FHIR elements must have a @value or children |
| section:sectionAssessments |
C | 1..1 | BackboneElement | Assessments 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 51848-0 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment ele-1: All FHIR elements must have a @value or children |
| section:sectionPregnancyHistory |
SC | 0..1 | BackboneElement | Pregnancy History 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations ele-1: All FHIR elements must have a @value or children |
| section:sectionCardiacArrestEvent |
C | 0..1 | BackboneElement | Cardiac Arrest Event 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 67799-7 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations ele-1: All FHIR elements must have a @value or children |
| section:sectionProviderOrders |
C | 0..1 | BackboneElement | Provider Orders 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children 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: 46209-3 | |
| text |
SC | 1..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children |
| entry |
SC | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.language | preferred | CommonLanguageshttp://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 | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | |
| Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodesfrom 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.event:careProvisioningEvent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | |
| Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | 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 |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained |
0..* | Resource | Contained, inline Resources | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| extension:participant_extension |
S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
SΣ | 1..1 | Identifier | Version-independent identifier for the Composition |
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| category:pstat |
Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 34133-9 | |
| 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 | |
| subject |
SΣ | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about |
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title |
SΣ | 1..1 | string | Human Readable name/title |
| confidentiality |
Σ | 1..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) | |||
| Slices for event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code |
| event:All Slices |
Content/Rules for all slices | |||
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period |
Σ | 0..1 | Period | The period covered by the documentation |
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented |
| event:careProvisioningEvent |
SΣ | 0..1 | BackboneElement | The 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 |
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. |
| period |
SΣ | 0..1 | Period | The period covered by the documentation |
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section |
C | 7..* | BackboneElement | Composition is broken into sections 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 | CodeableConcept | Classification of section (recommended) 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. | |
|