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 2024-09-03 | 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 | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | S | 1..1 | BackboneElement | IHE Active Problems Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
Slices for entry | S | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
Slices for entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
Slices for entry | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
Slices for entry | S | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:procedure | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section | |
section:sectionImmunizations | S | 0..1 | BackboneElement | IHE Immunizations Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
Slices for entry | S | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:immunizationAdministration | 0..* | Reference(MedicationAdministration) | A reference to data that supports this section | |
section:sectionSocialHistory | S | 0..1 | BackboneElement | IHE Social History Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
section:sectionVitalSigns | S | 0..1 | BackboneElement | Vital Signs Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
Slices for entry | S | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
Slices for entry | S | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | S | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | S | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:carePlan | 0..* | Reference(CarePlan) | A reference to data that supports this section | |
section:sectionAdvancedirectives | S | 0..1 | BackboneElement | IHE Advance directives section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
Slices for entry | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:advanceDirectivesConsent | 1..1 | Reference(Consent) | A reference to data that supports this section | |
section:sectionFunctionalStatus | S | 0..1 | BackboneElement | Functional Status |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
Slices for entry | S | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | 0..* | Reference(Condition) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:functionalAssessment | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
section:sectionPayers | 0..1 | BackboneElement | Payers Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | S | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:coverage | 0..* | Reference(Coverage) | A reference to data that supports this section | |
section:sectionIncident | S | 0..1 | BackboneElement | Incident Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | 0..1 | Reference(Incident) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:possibleInjury | 0..1 | Reference(Possible Injury) | A reference to data that supports this section | |
section:sectionTreatment | 0..1 | BackboneElement | Treatment Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 |
Slices for entry | Content/Rules for all slices | |||
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 | ||
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11283-9 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
section:sectionInjuryIncidentDescription | 0..1 | BackboneElement | Injury section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11374-6 | |
Slices for entry | S | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | 0..1 | Reference(Patient Activity) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | 0..1 | Reference(Height of Fall) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | 0..* | Reference(Collision Data) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:workPlaceInjuryIndicator | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section | |
section:sectionAssessments | 1..1 | BackboneElement | Assessments | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
section:sectionPregnancyHistory | S | 0..1 | BackboneElement | Pregnancy History |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
section:sectionCardiacArrestEvent | 0..1 | BackboneElement | Cardiac Arrest Event | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67799-7 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
section:sectionProviderOrders | 0..1 | BackboneElement | Provider Orders | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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/languages from 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 | |
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 |
Slices for extension | Content/Rules for all slices | |||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
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 |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
Slices for event | Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code |
event:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The clinical service(s) being documented |
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 |
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 | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
section: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:allergyOrIntolerance | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:pastProblem | C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:procedure | C | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
Slices for entry | SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:immunizationAdministration | C | 0..* | Reference(MedicationAdministration) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:employment | C | 0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
Slices for entry | SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:vitalSign | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
Slices for entry | SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:deviceStatement | C | 1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | SC | 0..* | Reference(Observation | DocumentReference) | Physical findings |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
section:heart | C | 1..1 | BackboneElement | Heart Exam |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:results-diagnosticReport | C | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
Slices for entry | C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:advanceDirectivesConsent | C | 1..1 | Reference(Consent) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
Slices for entry | SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | C | 0..* | Reference(Condition) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:functionalAssessment | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:coverage | C | 0..* | Reference(Coverage) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
Slices for entry | SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | C | 0..1 | Reference(Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:possibleInjury | C | 0..1 | Reference(Possible Injury) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
Slices for entry | SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:barriersToCare | C | 0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section |
Slices for section | C | 0..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code |
Slices for section | Content/Rules for all slices | |||
section:proceduresPerformed | SC | 0..* | BackboneElement | IHE Procedures and Interventions Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
Slices for section | Content/Rules for all slices | |||
section:medicationsAdministered | SC | 0..* | BackboneElement | IHE Medications Administered Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11283-9 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11374-6 | |
Slices for entry | SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | C | 0..* | Reference(Collision Data) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:workPlaceInjuryIndicator | C | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67799-7 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46209-3 | |
entry | SC | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from 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-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codes from 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 | |
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:chiefComplaintObservations | SC | 0..* | Reference(Observation) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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(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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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 | 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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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 | 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 |
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | C | 0..* | Reference(Condition) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | C | 0..1 | Reference(Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | C | 0..* | Reference(Collision Data) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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/languages from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.event:careProvisioningEvent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicalDevices.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionMedicalDevices.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionMedicalDevices.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCarePlan.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCarePlan.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCarePlan.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPayers.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPayers.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionIncident.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionIncident.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionIncident.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTriage.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTriage.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTriage.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAssessments.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAssessments.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAssessments.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProviderOrders.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProviderOrders.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProviderOrders.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from 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 | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | S | 1..1 | BackboneElement | IHE Active Problems Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
Slices for entry | S | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
Slices for entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
Slices for entry | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
Slices for entry | S | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:procedure | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section | |
section:sectionImmunizations | S | 0..1 | BackboneElement | IHE Immunizations Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
Slices for entry | S | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:immunizationAdministration | 0..* | Reference(MedicationAdministration) | A reference to data that supports this section | |
section:sectionSocialHistory | S | 0..1 | BackboneElement | IHE Social History Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
section:sectionVitalSigns | S | 0..1 | BackboneElement | Vital Signs Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
Slices for entry | S | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
Slices for entry | S | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | S | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | S | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:carePlan | 0..* | Reference(CarePlan) | A reference to data that supports this section | |
section:sectionAdvancedirectives | S | 0..1 | BackboneElement | IHE Advance directives section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
Slices for entry | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:advanceDirectivesConsent | 1..1 | Reference(Consent) | A reference to data that supports this section | |
section:sectionFunctionalStatus | S | 0..1 | BackboneElement | Functional Status |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
Slices for entry | S | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | 0..* | Reference(Condition) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:functionalAssessment | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
section:sectionPayers | 0..1 | BackboneElement | Payers Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | S | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:coverage | 0..* | Reference(Coverage) | A reference to data that supports this section | |
section:sectionIncident | S | 0..1 | BackboneElement | Incident Section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | 0..1 | Reference(Incident) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:possibleInjury | 0..1 | Reference(Possible Injury) | A reference to data that supports this section | |
section:sectionTreatment | 0..1 | BackboneElement | Treatment Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 |
Slices for entry | Content/Rules for all slices | |||
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 | ||
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11283-9 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
section:sectionInjuryIncidentDescription | 0..1 | BackboneElement | Injury section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11374-6 | |
Slices for entry | S | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | 0..1 | Reference(Patient Activity) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | 0..1 | Reference(Height of Fall) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | 0..* | Reference(Collision Data) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:workPlaceInjuryIndicator | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this section | |
section:sectionAssessments | 1..1 | BackboneElement | Assessments | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
section:sectionPregnancyHistory | S | 0..1 | BackboneElement | Pregnancy History |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
section:sectionCardiacArrestEvent | 0..1 | BackboneElement | Cardiac Arrest Event | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67799-7 | |
entry | S | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
section:sectionProviderOrders | 0..1 | BackboneElement | Provider Orders | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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/languages from 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 | |
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 |
Slices for extension | Content/Rules for all slices | |||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
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 |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
Slices for event | Σ | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code |
event:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The clinical service(s) being documented |
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 |
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 | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
section: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29299-5 | |
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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: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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:allergyOrIntolerance | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:pastProblem | C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:procedure | C | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
Slices for entry | SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:immunizationAdministration | C | 0..* | Reference(MedicationAdministration) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:employment | C | 0..* | Reference(Employment Status | Usual Work) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
Slices for entry | SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:vitalSign | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
Slices for entry | SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:deviceStatement | C | 1..1 | Reference(Device Use Statement (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | SC | 0..* | Reference(Observation | DocumentReference) | Physical findings |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
section:heart | C | 1..1 | BackboneElement | Heart Exam |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:results-diagnosticReport | C | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
Slices for entry | C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:advanceDirectivesConsent | C | 1..1 | Reference(Consent) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
Slices for entry | SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | C | 0..* | Reference(Condition) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:functionalAssessment | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
Slices for entry | SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:coverage | C | 0..* | Reference(Coverage) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 272379006 | |
Slices for entry | SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | C | 0..1 | Reference(Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:possibleInjury | C | 0..1 | Reference(Possible Injury) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 182991002 | |
Slices for entry | SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:barriersToCare | C | 0..1 | Reference(IHE barriers to care observation) | A reference to data that supports this section |
Slices for section | C | 0..* | See section (Composition) | Nested Section Slice: Unordered, Open by pattern:code |
Slices for section | Content/Rules for all slices | |||
section:proceduresPerformed | SC | 0..* | BackboneElement | IHE Procedures and Interventions Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
Slices for section | Content/Rules for all slices | |||
section:medicationsAdministered | SC | 0..* | BackboneElement | IHE Medications Administered Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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 | |
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 |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11283-9 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11374-6 | |
Slices for entry | SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | C | 0..* | Reference(Collision Data) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:workPlaceInjuryIndicator | C | 0..* | Reference(Work Place Injury Indicator) | A reference to data that supports this 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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Acuity Assessment |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Pregnancy Observations |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67799-7 | |
entry | SC | 0..1 | Reference(Observation | DocumentReference) | Cardiac Arrest Event Observations |
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 |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46209-3 | |
entry | SC | 0..1 | Reference(Medication | MedicationRequest | Procedure | DocumentReference) | Provider Orders |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from 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-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codes from 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 | |
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:chiefComplaintObservations | SC | 0..* | Reference(Observation) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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(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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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 | 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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | C | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | C | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | C | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | DocumentReference) | Vital Signs Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 1..* | Reference(DeviceUseStatement | DocumentReference) | medical device use Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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 | 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 |
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | results observations Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:results-observation | C | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(CarePlan | DocumentReference) | Plans of Care Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | C | 1..* | Reference(Consent | DocumentReference) | advance directive Consent Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | disabilities and functional assessments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:disability | C | 0..* | Reference(Condition) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Coverage | DocumentReference) | Coverage Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | Encounter | DocumentReference) | Incident data Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:incidentEvent | C | 0..1 | Reference(Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:numberOfAffectedPeople | C | 0..1 | Reference(Number of Affected People) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:MassCasualtyIncidentIndicator | C | 0..1 | Reference(PSC Mass Casualty Incident) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 1..* | Reference(Observation | Procedure | MedicationAdministration | DocumentReference) | Treatments Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 |
Slices for section | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
Slices for entry | SC | 0..* | Reference(Observation | Condition (IPS) | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Injury observation entires Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:patientActivity | C | 0..1 | Reference(Patient Activity) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryCause | C | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:injuryMechanism | C | 0..* | Reference(Mechanism of Injury) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:heightOfFall | C | 0..1 | Reference(Height of Fall) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:protectiveEquipmentUsed | C | 0..* | Reference(Protective Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:safetyEquipmentUsed | C | 0..* | Reference(Safety Equipment Used) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
entry:collissionData | C | 0..* | Reference(Collision Data) | A reference to data that supports this section |
Slices for entry | Content/Rules for all slices | |||
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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 | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | 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..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/languages from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 34133-9http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.event:careProvisioningEvent.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionDetailedChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.code | example | Pattern: LOINC Code 29299-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedReasonforVisit.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.code | example | Pattern: LOINC Code 10164-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPresentIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionReviewOfSystems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC Code 46264-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicalDevices.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionMedicalDevices.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionMedicalDevices.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.code | example | Pattern: LOINC Code 11412-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:respiratorySystem.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.code | example | Pattern: LOINC Code 10200-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCodedDetailPhysicalExamination.section:heart.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCarePlan.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCarePlan.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCarePlan.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCarePlan.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAdvancedirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC Code 47420-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionFunctionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPayers.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPayers.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionIncident.code | example | Pattern: SNOMED-CT Code 272379006http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionIncident.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionIncident.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionIncident.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.code | example | Pattern: SNOMED-CT Code 182991002http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.code | example | Pattern: LOINC Code 29554-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.section:proceduresPerformed.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.code | example | Pattern: LOINC Code 18610-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTreatment.section:medicationsAdministered.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionTriage.code | example | Pattern: LOINC Code 11283-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTriage.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionTriage.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionTriage.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.code | example | Pattern: LOINC Code 11374-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionInjuryIncidentDescription.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAssessments.code | example | Pattern: LOINC Code 51848-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAssessments.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionAssessments.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionAssessments.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionPregnancyHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.code | example | Pattern: LOINC Code 67799-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionCardiacArrestEvent.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProviderOrders.code | example | Pattern: LOINC Code 46209-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProviderOrders.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section:sectionProviderOrders.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | |
Composition.section:sectionProviderOrders.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from 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:
Other representations of profile: CSV, Excel, Schematron