IHE PCC - Routine Interfacility Patient Transport (RIPT)
2.0.0-draft - ci-build
IHE PCC - Routine Interfacility Patient Transport (RIPT)
2.0.0-draft - ci-build
IHE PCC - Routine Interfacility Patient Transport (RIPT), published by IHE Patient Care Coordination. This is not an authorized publication; it is the continuous build for version 2.0.0-draft). This version is based on the current content of https://github.com/IHE/PCC.RIPT/ and changes regularly. See the Directory of published versions
| Official URL: http://profiles.ihe.net/PCC/RIPT/StructureDefinition/IHE.PCC.RIPT.Composition | Version: 2.0.0-draft | |||
| Active as of 2023-01-27 | Computable Name: IHE_RIPT_Composition | |||
composition of the FHIR elements that are used to build the FHIR Document for the Refferal For Interfacility Patient Transport document. the following cardinalities follow the documentation in the RIPT profile:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CompositionUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | CompositionUvIps | International Patient Summary composition | |
  subject | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about | |
| section | 3..* | BackboneElement | Sections composing the IPS | |
 section:sectionCertificationOfMedicalNecessity | 0..1 | BackboneElement | Certification of Medical Necessity | |
  code | S | 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: 52016-3 | |
  Slices for entry | S | 0..* | Reference(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() |
 entry:MedicalNecessityEntry | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:Signature | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignatureDate | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignerProviderType | S | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section |
| entry:SignerName | S | 0..1 | Reference(Practitioner) | A reference to data that supports this section |
| entry:Justification | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ReasonForTransport | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCode | 0..1 | Reference(Observation) | A reference to data that supports this section | |
 entry:PriorAuthorizationCodePayer | 0..1 | Reference(Observation) | A reference to data that supports this section | |
| section:sectionCoverage | 0..1 | BackboneElement | Insurance Section | |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
| Slices for entry | S | 0..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() |
| entry:Coverage | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:sectionReasonForReferral | 0..1 | BackboneElement | Reason for Referral | |
| code | S | 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: 42349-1 | |
| Slices for entry | S | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() |
| entry:SimpleObservations | S | 1..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ConditionsEntry | S | 1..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionTransportInstructions | 0..1 | BackboneElement | Transport Instructions | |
| code | S | 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: 74213-0 | |
| Slices for entry | S | 0..* | Reference(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() |
| entry:TrasnportInstructions | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:DestinationInformation | S | 0..1 | Reference(Location) | A reference to data that supports this section |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | S | 0..* | CompositionUvIps | International Patient Summary composition |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
 subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about |
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | SΣ | 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 IPS |
| title | SΣ | 1..1 | string | International Patient Summary |
| confidentiality | SΣ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| 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 | S | 0..* | BackboneElement | Relationships to other compositions/documents |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. |
 target[x] | S | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition | Composition (IPS)) | |||
| Slices for event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code |
| event:All Slices | Content/Rules for all slices | |||
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning being documented |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | SΣ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
| period | SΣ | 0..1 | Period | The period covered by the documentation |
| Slices for section | SC | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Medication Summary section |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:$this.resolve() |
| entry:medicationStatement | SC | 1..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:$this.resolve() |
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
| section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:$this.resolve() |
| entry:problem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:$this.resolve() |
| entry:procedure | SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizations | SC | 0..1 | BackboneElement | IPS Immunizations Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:$this.resolve() |
| entry:immunization | SC | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open by profile:$this.resolve() |
| entry:deviceStatement | SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResults | SC | 0..1 | BackboneElement | IPS Results Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve() |
| entry:results-observation | SC | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | A reference to data that supports this section |
| entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
| section:sectionVitalSigns | SC | 0..1 | BackboneElement | IPS Vital Signs Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:$this.resolve() |
| entry:vitalSign | SC | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
| section:sectionPastIllnessHx | SC | 0..1 | BackboneElement | IPS History of Past Illness Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:$this.resolve() |
| entry:pastProblem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionFunctionalStatus | SC | 0..1 | BackboneElement | IPS Functional Status |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:$this.resolve() |
| entry:disability | SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| entry:functionalAssessment | SC | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
| section:sectionPlanOfCare | SC | 0..1 | BackboneElement | IPS Plan of Care Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | C | 0..* | Reference(Resource) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:$this.resolve() |
| entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| section:sectionSocialHistory | SC | 0..1 | BackboneElement | IPS Social History Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:$this.resolve() |
| entry:smokingTobaccoUse | SC | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section |
| entry:alcoholUse | SC | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section |
| section:sectionPregnancyHx | SC | 0..1 | BackboneElement | IPS History of Pregnancy Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyStatus | SC | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section |
| entry:pregnancyOutcomeSummary | SC | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section |
| section:sectionAdvanceDirectives | SC | 0..1 | BackboneElement | IPS Advance Directives Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:$this.resolve() |
| entry:advanceDirectivesConsent | SC | 0..* | Reference(Consent) | A reference to data that supports this section |
| section:sectionCertificationOfMedicalNecessity | SC | 0..1 | BackboneElement | Certification of Medical Necessity |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 52016-3 | |
| Slices for entry | SC | 0..* | Reference(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() |
| entry:MedicalNecessityEntry | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:Signature | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignatureDate | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignerProviderType | SC | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section |
| entry:SignerName | SC | 0..1 | Reference(Practitioner) | A reference to data that supports this section |
| entry:Justification | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ReasonForTransport | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCode | C | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCodePayer | C | 0..1 | Reference(Observation) | A reference to data that supports this section |
| section:sectionCoverage | SC | 0..1 | BackboneElement | Insurance Section |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | 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..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() |
| entry:Coverage | SC | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:sectionReasonForReferral | SC | 0..1 | BackboneElement | Reason for Referral |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |
| Slices for entry | SC | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() |
| entry:SimpleObservations | SC | 1..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ConditionsEntry | SC | 1..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionTransportInstructions | SC | 0..1 | BackboneElement | Transport Instructions |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74213-0 | |
| Slices for entry | SC | 0..* | Reference(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() |
| entry:TrasnportInstructions | SC | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:DestinationInformation | SC | 0..1 | Reference(Location) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 60591-5 |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPR |
| Composition.section:sectionMedications.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:sectionProblems.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC code 47519-4 |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC code 11369-6 |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC code 46264-8 |
| Composition.section:sectionResults.code | example | Pattern: LOINC code 30954-2 |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC code 8716-3 |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC code 11348-0 |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC code 47420-5 |
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC code 18776-5 |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC code 29762-2 |
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC code 10162-6 |
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC code 42348-3 |
| Composition.section:sectionCertificationOfMedicalNecessity.code | example | Pattern: LOINC code 52016-3 |
| Composition.section:sectionCoverage.code | example | Pattern: LOINC code 48768-6 |
| Composition.section:sectionReasonForReferral.code | example | Pattern: LOINC code 42349-1 |
| Composition.section:sectionTransportInstructions.code | example | Pattern: LOINC code 74213-0 |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | S | 0..* | CompositionUvIps | International Patient Summary composition | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 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 | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | SΣ | 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 IPS | ||||
| title | SΣ | 1..1 | string | International Patient Summary | ||||
| confidentiality | SΣ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
| time | S | 0..1 | dateTime | When the composition was attested | ||||
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
| custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | S | 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 | S | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target[x] | S | 1..1 | Target of the relationship | |||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition | Composition (IPS)) | |||||||
| Slices for event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | ||||
| event:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning 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..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| period | SΣ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code | ||||
| 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 | 0..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 | 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:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary 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 | S | 1..1 | string | Medication Summary section | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:medicationStatement | SC | 1..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | ||||
| section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:problem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:procedure | SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section | ||||
| section:sectionImmunizations | SC | 0..1 | BackboneElement | IPS Immunizations 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:immunization | SC | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section | ||||
| section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:deviceStatement | SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section | ||||
| section:sectionResults | SC | 0..1 | BackboneElement | IPS Results 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve() | ||||
| entry:results-observation | SC | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | A reference to data that supports this section | ||||
| entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section | ||||
| section:sectionVitalSigns | SC | 0..1 | BackboneElement | IPS Vital Signs 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:vitalSign | SC | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | ||||
| section:sectionPastIllnessHx | SC | 0..1 | BackboneElement | IPS History of Past Illness 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pastProblem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| section:sectionFunctionalStatus | SC | 0..1 | BackboneElement | IPS Functional Status | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:disability | SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| entry:functionalAssessment | SC | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | ||||
| section:sectionPlanOfCare | SC | 0..1 | BackboneElement | IPS Plan of Care 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section | ||||
| section:sectionSocialHistory | SC | 0..1 | BackboneElement | IPS Social History 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:smokingTobaccoUse | SC | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section | ||||
| entry:alcoholUse | SC | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section | ||||
| section:sectionPregnancyHx | SC | 0..1 | BackboneElement | IPS History of Pregnancy 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pregnancyStatus | SC | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section | ||||
| entry:pregnancyOutcomeSummary | SC | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section | ||||
| section:sectionAdvanceDirectives | SC | 0..1 | BackboneElement | IPS Advance Directives 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:advanceDirectivesConsent | SC | 0..* | Reference(Consent) | A reference to data that supports this section | ||||
| section:sectionCertificationOfMedicalNecessity | SC | 0..1 | BackboneElement | Certification of Medical Necessity | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 52016-3 | |||||
| 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(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:MedicalNecessityEntry | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:Signature | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:SignatureDate | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:SignerProviderType | SC | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section | ||||
| entry:SignerName | SC | 0..1 | Reference(Practitioner) | A reference to data that supports this section | ||||
| entry:Justification | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:ReasonForTransport | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:PriorAuthorizationCode | C | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:PriorAuthorizationCodePayer | C | 0..1 | Reference(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. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionCoverage | SC | 0..1 | BackboneElement | Insurance 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 | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | 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..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() | ||||
| entry:Coverage | SC | 0..1 | 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:sectionReasonForReferral | SC | 0..1 | BackboneElement | Reason for Referral | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |||||
| 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. | |||||
| Slices for entry | SC | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() | ||||
| entry:SimpleObservations | SC | 1..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:ConditionsEntry | SC | 1..1 | 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:sectionTransportInstructions | SC | 0..1 | BackboneElement | Transport Instructions | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74213-0 | |||||
| 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(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() | ||||
| entry:TrasnportInstructions | SC | 0..1 | Reference(Resource) | A reference to data that supports this section | ||||
| entry:DestinationInformation | SC | 0..1 | Reference(Location) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 60591-5 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPR | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionMedications.code | example | Pattern: LOINC code 10160-0 | ||||
| Composition.section:sectionMedications.mode | required | ListMode | ||||
| Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2 | ||||
| Composition.section:sectionAllergies.mode | required | ListMode | ||||
| Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionProblems.code | example | Pattern: LOINC code 11450-4 | ||||
| Composition.section:sectionProblems.mode | required | ListMode | ||||
| Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC code 47519-4 | ||||
| Composition.section:sectionProceduresHx.mode | required | ListMode | ||||
| Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC code 11369-6 | ||||
| Composition.section:sectionImmunizations.mode | required | ListMode | ||||
| Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC code 46264-8 | ||||
| Composition.section:sectionMedicalDevices.mode | required | ListMode | ||||
| Composition.section:sectionMedicalDevices.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionResults.code | example | Pattern: LOINC code 30954-2 | ||||
| Composition.section:sectionResults.mode | required | ListMode | ||||
| Composition.section:sectionResults.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC code 8716-3 | ||||
| Composition.section:sectionVitalSigns.mode | required | ListMode | ||||
| Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC code 11348-0 | ||||
| Composition.section:sectionPastIllnessHx.mode | required | ListMode | ||||
| Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC code 47420-5 | ||||
| Composition.section:sectionFunctionalStatus.mode | required | ListMode | ||||
| Composition.section:sectionFunctionalStatus.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC code 18776-5 | ||||
| Composition.section:sectionPlanOfCare.mode | required | ListMode | ||||
| Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC code 29762-2 | ||||
| Composition.section:sectionSocialHistory.mode | required | ListMode | ||||
| Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC code 10162-6 | ||||
| Composition.section:sectionPregnancyHx.mode | required | ListMode | ||||
| Composition.section:sectionPregnancyHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC code 42348-3 | ||||
| Composition.section:sectionAdvanceDirectives.mode | required | ListMode | ||||
| Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.code | example | Pattern: LOINC code 52016-3 | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.mode | required | ListMode | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionCoverage.code | example | Pattern: LOINC code 48768-6 | ||||
| Composition.section:sectionCoverage.mode | required | ListMode | ||||
| Composition.section:sectionCoverage.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCoverage.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionReasonForReferral.code | example | Pattern: LOINC code 42349-1 | ||||
| Composition.section:sectionReasonForReferral.mode | required | ListMode | ||||
| Composition.section:sectionReasonForReferral.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionReasonForReferral.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionTransportInstructions.code | example | Pattern: LOINC code 74213-0 | ||||
| Composition.section:sectionTransportInstructions.mode | required | ListMode | ||||
| Composition.section:sectionTransportInstructions.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionTransportInstructions.emptyReason | preferred | ListEmptyReasons |
This structure is derived from CompositionUvIps
Summary
Mandatory: 1 element (6 nested mandatory elements)
Must-Support: 20 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CompositionUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | CompositionUvIps | International Patient Summary composition | |
| subject | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about | |
| section | 3..* | BackboneElement | Sections composing the IPS | |
| section:sectionCertificationOfMedicalNecessity | 0..1 | BackboneElement | Certification of Medical Necessity | |
| code | S | 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: 52016-3 | |
| Slices for entry | S | 0..* | Reference(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() |
| entry:MedicalNecessityEntry | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:Signature | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignatureDate | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignerProviderType | S | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section |
| entry:SignerName | S | 0..1 | Reference(Practitioner) | A reference to data that supports this section |
| entry:Justification | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ReasonForTransport | S | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCode | 0..1 | Reference(Observation) | A reference to data that supports this section | |
| entry:PriorAuthorizationCodePayer | 0..1 | Reference(Observation) | A reference to data that supports this section | |
| section:sectionCoverage | 0..1 | BackboneElement | Insurance Section | |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
| Slices for entry | S | 0..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() |
| entry:Coverage | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:sectionReasonForReferral | 0..1 | BackboneElement | Reason for Referral | |
| code | S | 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: 42349-1 | |
| Slices for entry | S | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() |
| entry:SimpleObservations | S | 1..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ConditionsEntry | S | 1..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionTransportInstructions | 0..1 | BackboneElement | Transport Instructions | |
| code | S | 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: 74213-0 | |
| Slices for entry | S | 0..* | Reference(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() |
| entry:TrasnportInstructions | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:DestinationInformation | S | 0..1 | Reference(Location) | A reference to data that supports this section |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | S | 0..* | CompositionUvIps | International Patient Summary composition |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about |
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | SΣ | 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 IPS |
| title | SΣ | 1..1 | string | International Patient Summary |
| confidentiality | SΣ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| 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 | S | 0..* | BackboneElement | Relationships to other compositions/documents |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. |
| target[x] | S | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition | Composition (IPS)) | |||
| Slices for event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code |
| event:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning being documented |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | SΣ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
| period | SΣ | 0..1 | Period | The period covered by the documentation |
| Slices for section | SC | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Medication Summary section |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:$this.resolve() |
| entry:medicationStatement | SC | 1..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:$this.resolve() |
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
| section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:$this.resolve() |
| entry:problem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:$this.resolve() |
| entry:procedure | SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
| section:sectionImmunizations | SC | 0..1 | BackboneElement | IPS Immunizations Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:$this.resolve() |
| entry:immunization | SC | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
| section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open by profile:$this.resolve() |
| entry:deviceStatement | SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
| section:sectionResults | SC | 0..1 | BackboneElement | IPS Results Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve() |
| entry:results-observation | SC | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | A reference to data that supports this section |
| entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
| section:sectionVitalSigns | SC | 0..1 | BackboneElement | IPS Vital Signs Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:$this.resolve() |
| entry:vitalSign | SC | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
| section:sectionPastIllnessHx | SC | 0..1 | BackboneElement | IPS History of Past Illness Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 1..* | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:$this.resolve() |
| entry:pastProblem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionFunctionalStatus | SC | 0..1 | BackboneElement | IPS Functional Status |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:$this.resolve() |
| entry:disability | SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
| entry:functionalAssessment | SC | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
| section:sectionPlanOfCare | SC | 0..1 | BackboneElement | IPS Plan of Care Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | C | 0..* | Reference(Resource) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:$this.resolve() |
| entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| section:sectionSocialHistory | SC | 0..1 | BackboneElement | IPS Social History Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:$this.resolve() |
| entry:smokingTobaccoUse | SC | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section |
| entry:alcoholUse | SC | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section |
| section:sectionPregnancyHx | SC | 0..1 | BackboneElement | IPS History of Pregnancy Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyStatus | SC | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section |
| entry:pregnancyOutcomeSummary | SC | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section |
| section:sectionAdvanceDirectives | SC | 0..1 | BackboneElement | IPS Advance Directives Section |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | |
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | SC | 0..* | Reference(Resource) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:$this.resolve() |
| entry:advanceDirectivesConsent | SC | 0..* | Reference(Consent) | A reference to data that supports this section |
| section:sectionCertificationOfMedicalNecessity | SC | 0..1 | BackboneElement | Certification of Medical Necessity |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 52016-3 | |
| Slices for entry | SC | 0..* | Reference(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() |
| entry:MedicalNecessityEntry | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:Signature | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignatureDate | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:SignerProviderType | SC | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section |
| entry:SignerName | SC | 0..1 | Reference(Practitioner) | A reference to data that supports this section |
| entry:Justification | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ReasonForTransport | SC | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCode | C | 0..1 | Reference(Observation) | A reference to data that supports this section |
| entry:PriorAuthorizationCodePayer | C | 0..1 | Reference(Observation) | A reference to data that supports this section |
| section:sectionCoverage | SC | 0..1 | BackboneElement | Insurance Section |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | 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..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() |
| entry:Coverage | SC | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:sectionReasonForReferral | SC | 0..1 | BackboneElement | Reason for Referral |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |
| Slices for entry | SC | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() |
| entry:SimpleObservations | SC | 1..1 | Reference(Observation) | A reference to data that supports this section |
| entry:ConditionsEntry | SC | 1..1 | Reference(Condition (IPS)) | A reference to data that supports this section |
| section:sectionTransportInstructions | SC | 0..1 | BackboneElement | Transport Instructions |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74213-0 | |
| Slices for entry | SC | 0..* | Reference(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() |
| entry:TrasnportInstructions | SC | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:DestinationInformation | SC | 0..1 | Reference(Location) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 60591-5 |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPR |
| Composition.section:sectionMedications.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:sectionProblems.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC code 47519-4 |
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC code 11369-6 |
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC code 46264-8 |
| Composition.section:sectionResults.code | example | Pattern: LOINC code 30954-2 |
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC code 8716-3 |
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC code 11348-0 |
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC code 47420-5 |
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC code 18776-5 |
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC code 29762-2 |
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC code 10162-6 |
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC code 42348-3 |
| Composition.section:sectionCertificationOfMedicalNecessity.code | example | Pattern: LOINC code 52016-3 |
| Composition.section:sectionCoverage.code | example | Pattern: LOINC code 48768-6 |
| Composition.section:sectionReasonForReferral.code | example | Pattern: LOINC code 42349-1 |
| Composition.section:sectionTransportInstructions.code | example | Pattern: LOINC code 74213-0 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | S | 0..* | CompositionUvIps | International Patient Summary composition | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| 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 | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | SΣ | 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 IPS | ||||
| title | SΣ | 1..1 | string | International Patient Summary | ||||
| confidentiality | SΣ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
| time | S | 0..1 | dateTime | When the composition was attested | ||||
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
| custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | S | 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 | S | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target[x] | S | 1..1 | Target of the relationship | |||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition | Composition (IPS)) | |||||||
| Slices for event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | ||||
| event:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning 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..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| period | SΣ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 3..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code | ||||
| 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 | 0..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 | 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:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary 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 | S | 1..1 | string | Medication Summary section | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:medicationStatement | SC | 1..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
| section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:allergyOrIntolerance | SC | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | ||||
| section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:problem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:procedure | SC | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section | ||||
| section:sectionImmunizations | SC | 0..1 | BackboneElement | IPS Immunizations 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:immunization | SC | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section | ||||
| section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:deviceStatement | SC | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section | ||||
| section:sectionResults | SC | 0..1 | BackboneElement | IPS Results 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:$this.resolve(), profile:$this.resolve() | ||||
| entry:results-observation | SC | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | A reference to data that supports this section | ||||
| entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section | ||||
| section:sectionVitalSigns | SC | 0..1 | BackboneElement | IPS Vital Signs 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:vitalSign | SC | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | ||||
| section:sectionPastIllnessHx | SC | 0..1 | BackboneElement | IPS History of Past Illness 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pastProblem | SC | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| section:sectionFunctionalStatus | SC | 0..1 | BackboneElement | IPS Functional Status | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:disability | SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | ||||
| entry:functionalAssessment | SC | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | ||||
| section:sectionPlanOfCare | SC | 0..1 | BackboneElement | IPS Plan of Care 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | C | 0..* | Reference(Resource) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section | ||||
| section:sectionSocialHistory | SC | 0..1 | BackboneElement | IPS Social History 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:smokingTobaccoUse | SC | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section | ||||
| entry:alcoholUse | SC | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section | ||||
| section:sectionPregnancyHx | SC | 0..1 | BackboneElement | IPS History of Pregnancy 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pregnancyStatus | SC | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section | ||||
| entry:pregnancyOutcomeSummary | SC | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section | ||||
| section:sectionAdvanceDirectives | SC | 0..1 | BackboneElement | IPS Advance Directives 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 | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 0..* | Reference(Resource) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:advanceDirectivesConsent | SC | 0..* | Reference(Consent) | A reference to data that supports this section | ||||
| section:sectionCertificationOfMedicalNecessity | SC | 0..1 | BackboneElement | Certification of Medical Necessity | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 52016-3 | |||||
| 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(Resource) | Medical Necessity Entry Slice: Unordered, Open by profile:resolve() | ||||
| entry:MedicalNecessityEntry | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:Signature | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:SignatureDate | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:SignerProviderType | SC | 0..1 | Reference(PractitionerRole) | A reference to data that supports this section | ||||
| entry:SignerName | SC | 0..1 | Reference(Practitioner) | A reference to data that supports this section | ||||
| entry:Justification | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:ReasonForTransport | SC | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:PriorAuthorizationCode | C | 0..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:PriorAuthorizationCodePayer | C | 0..1 | Reference(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. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionCoverage | SC | 0..1 | BackboneElement | Insurance 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 | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | 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..1 | Reference(Coverage) | the Patient's insurance information Slice: Unordered, Open by profile:resolve() | ||||
| entry:Coverage | SC | 0..1 | 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:sectionReasonForReferral | SC | 0..1 | BackboneElement | Reason for Referral | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42349-1 | |||||
| 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. | |||||
| Slices for entry | SC | 2..2 | Reference(Resource) | Certification of Medical Necessity Slice: Unordered, Open by profile:resolve() | ||||
| entry:SimpleObservations | SC | 1..1 | Reference(Observation) | A reference to data that supports this section | ||||
| entry:ConditionsEntry | SC | 1..1 | 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:sectionTransportInstructions | SC | 0..1 | BackboneElement | Transport Instructions | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74213-0 | |||||
| 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(Resource) | Transport Instructions Section Entries Slice: Unordered, Open by profile:resolve() | ||||
| entry:TrasnportInstructions | SC | 0..1 | Reference(Resource) | A reference to data that supports this section | ||||
| entry:DestinationInformation | SC | 0..1 | Reference(Location) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 60591-5 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.event:careProvisioningEvent.code | example | Pattern: PCPR | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionMedications.code | example | Pattern: LOINC code 10160-0 | ||||
| Composition.section:sectionMedications.mode | required | ListMode | ||||
| Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2 | ||||
| Composition.section:sectionAllergies.mode | required | ListMode | ||||
| Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionProblems.code | example | Pattern: LOINC code 11450-4 | ||||
| Composition.section:sectionProblems.mode | required | ListMode | ||||
| Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionProceduresHx.code | example | Pattern: LOINC code 47519-4 | ||||
| Composition.section:sectionProceduresHx.mode | required | ListMode | ||||
| Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionImmunizations.code | example | Pattern: LOINC code 11369-6 | ||||
| Composition.section:sectionImmunizations.mode | required | ListMode | ||||
| Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionMedicalDevices.code | example | Pattern: LOINC code 46264-8 | ||||
| Composition.section:sectionMedicalDevices.mode | required | ListMode | ||||
| Composition.section:sectionMedicalDevices.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionResults.code | example | Pattern: LOINC code 30954-2 | ||||
| Composition.section:sectionResults.mode | required | ListMode | ||||
| Composition.section:sectionResults.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionVitalSigns.code | example | Pattern: LOINC code 8716-3 | ||||
| Composition.section:sectionVitalSigns.mode | required | ListMode | ||||
| Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC code 11348-0 | ||||
| Composition.section:sectionPastIllnessHx.mode | required | ListMode | ||||
| Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionFunctionalStatus.code | example | Pattern: LOINC code 47420-5 | ||||
| Composition.section:sectionFunctionalStatus.mode | required | ListMode | ||||
| Composition.section:sectionFunctionalStatus.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC code 18776-5 | ||||
| Composition.section:sectionPlanOfCare.mode | required | ListMode | ||||
| Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionSocialHistory.code | example | Pattern: LOINC code 29762-2 | ||||
| Composition.section:sectionSocialHistory.mode | required | ListMode | ||||
| Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC code 10162-6 | ||||
| Composition.section:sectionPregnancyHx.mode | required | ListMode | ||||
| Composition.section:sectionPregnancyHx.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC code 42348-3 | ||||
| Composition.section:sectionAdvanceDirectives.mode | required | ListMode | ||||
| Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.code | example | Pattern: LOINC code 52016-3 | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.mode | required | ListMode | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCertificationOfMedicalNecessity.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionCoverage.code | example | Pattern: LOINC code 48768-6 | ||||
| Composition.section:sectionCoverage.mode | required | ListMode | ||||
| Composition.section:sectionCoverage.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionCoverage.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionReasonForReferral.code | example | Pattern: LOINC code 42349-1 | ||||
| Composition.section:sectionReasonForReferral.mode | required | ListMode | ||||
| Composition.section:sectionReasonForReferral.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionReasonForReferral.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionTransportInstructions.code | example | Pattern: LOINC code 74213-0 | ||||
| Composition.section:sectionTransportInstructions.mode | required | ListMode | ||||
| Composition.section:sectionTransportInstructions.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionTransportInstructions.emptyReason | preferred | ListEmptyReasons |
This structure is derived from CompositionUvIps
Summary
Mandatory: 1 element (6 nested mandatory elements)
Must-Support: 20 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ IHE Patient Care Coordination. Package ihe.pcc.ript#2.0.0-draft based on FHIR 4.0.1. Generated 2023-01-27
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