UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1 International flag

UV_Vital Records Birth and Fetal Death Reporting, published by IHE International. This is not an authorized publication; it is the continuous build for version 1.1.0). This version is based on the current content of https://github.com/IHE/fhir-bfdr/ and changes regularly. See the Directory of published versions

Resource Profile: CompositionProviderLiveBirthReport - Detailed Descriptions

Active as of 2023-10-20

Definitions for the Composition-provider-live-birth-report resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Composition
ShortProvider Live Birth Report
2. Composition.extension
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
4. Composition.extension:liveBirthCertificateNumber
Slice NameliveBirthCertificateNumber
ShortBirth Number
Control0..1
TypeExtension(Extension - Live Birth Certificate Number) (Extension Type: Identifier)
Must Supporttrue
6. Composition.extension:liveBirthLocalFileNumber
Slice NameliveBirthLocalFileNumber
ShortLocal File No.
Control0..1
TypeExtension(Extension - Live Birth Local File Number) (Extension Type: Identifier)
Must Supporttrue
8. Composition.extension:dateFiledByRegistrar
Slice NamedateFiledByRegistrar
ShortDate filed by registrar
Control1..1
TypeExtension(Extension - Date Filed by Registrar) (Extension Type: dateTime)
Must Supporttrue
10. Composition.extension:replacementStatus
Slice NamereplacementStatus
Control0..1
TypeExtension(Extension - Replacement Status) (Extension Type: CodeableConcept)
Must Supporttrue
12. Composition.status
Definition

In the case of a live birth sent in error, a status of 'entered-in-error' must be set.

ShortIn the case of a live birth sent in error, a status of 'entered-in-error' must be set.
Must Supporttrue
14. Composition.type
Definition

U.S. standard certificate of live birth - 2003 revision

ShortU.S. standard certificate of live birth - 2003 revision
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;68998-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
16. Composition.subject
Definition

The subject of the composition as a whole is the newborn baby. Different sections in the composition have different focus (e.g.: the mother).

ShortThe subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name.
Control1..?
TypeReference(Patient - Child - Vital Records)
Must Supporttrue
18. Composition.encounter
Definition

The Encounter for the Composition is the newborn's birth encounter. This Encounter links to the mother's encounter by the Encounter.partOf data element.

ShortThe Encounter for the Composition is the newborn's birth encounter.
TypeReference(Encounter - Birth)
Must Supporttrue
20. Composition.encounter.extension
ShortThe Encounter is the maternity encounter.
Control0..1
TypeExtension(Extension - Encounter Maternity Reference) (Extension Type: Reference(Encounter - Maternity))
22. Composition.date
ShortDate report completed
Must Supporttrue
24. Composition.author
Definition

Name and title of person completing the report. May be, but need not be, the same as the attendant at delivery.

ShortThe author is the person who verifies/approves the accuracy of the data to be sent to the vital records system.
Control0..1
TypeReference(Practitioner - Vital Records)
Must Supporttrue
26. Composition.section
Definition

The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Various administrative and demographic data in the Birth Certificate are contained in other locations in the Composition, such as the Patient and Encounter profiles.

ShortThe Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate.
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ code
28. Composition.section:motherPrenatal
Slice NamemotherPrenatal
Definition

This section contains items from the Mother (prenatal) on theLive Birth Certificate.

ShortMother (prenatal) section on the Live Birth Certificate
Control0..1
Must Supporttrue
30. Composition.section:motherPrenatal.code
Definition

Prenatal records

ShortPrenatal records
Control1..?
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57073-9&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
32. Composition.section:motherPrenatal.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.

ShortThe focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity.
Control1..?
TypeReference(Patient - Mother - Vital Records)
Must Supporttrue
34. Composition.section:motherPrenatal.entry
Definition

Entries that are contained in the Mother Prenatal section

ShortEntries that are contained in the Mother Prenatal section
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
36. Composition.section:motherPrenatal.entry:plannedToDeliverAtHome
Slice NameplannedToDeliverAtHome
Definition

Planned to deliver at home

ShortPlanned to deliver at home
Control0..1
TypeReference(Observation - Planned to Deliver at Home)
Must Supporttrue
38. Composition.section:motherPrenatal.entry:firstPrenatalCareVisit
Slice NamefirstPrenatalCareVisit
Definition

Date that mother had her first prenatal care visit.

ShortFirst prenatal care visit
Control0..1
TypeReference(Observation - Date of First Prenatal Care Visit)
Must Supporttrue
40. Composition.section:motherPrenatal.entry:numberPrenatalCareVisits
Slice NamenumberPrenatalCareVisits
Definition

Those visits which are listed in the mother's prenatal care and/or facility records.

ShortNumber of prenatal care visits
Control0..1
TypeReference(Observation - Number of Prenatal Visits - Vital Records)
Must Supporttrue
42. Composition.section:motherPrenatal.entry:dateLastNormalMenses
Slice NamedateLastNormalMenses
Definition

Date that the mother's last normal menses began. This item is used to compute the gestational age of the infant.

ShortDate last normal menses began
Control0..1
TypeReference(Observation - Last Menstrual Period - Vital Records)
Must Supporttrue
44. Composition.section:motherPrenatal.entry:numberNowLiving
Slice NamenumberNowLiving
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortNumber of previous live births now living
Control0..1
TypeReference(Observation - Number of Births Now Living - Vital Records)
Must Supporttrue
46. Composition.section:motherPrenatal.entry:numberNowDead
Slice NamenumberNowDead
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortNumber of previous live births now dead
Control0..1
TypeReference(Observation - Number of Births Now Dead - Vital Records)
Must Supporttrue
48. Composition.section:motherPrenatal.entry:dateLastLiveBirth
Slice NamedateLastLiveBirth
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortDate of last live birth
Control0..1
TypeReference(Observation - Date of Last Live Birth)
Must Supporttrue
50. Composition.section:motherPrenatal.entry:numberOtherOutcomes
Slice NamenumberOtherOutcomes
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).

ShortNumber of other pregnancy outcomes
Control0..1
TypeReference(Observation - Number of Other Pregnancy Outcomes - Vital Records)
Must Supporttrue
52. Composition.section:motherPrenatal.entry:dateLastOtherOutcome
Slice NamedateLastOtherOutcome
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).

ShortDate of last other pregnancy outcome
Control0..1
TypeReference(Observation - Date of Last Other Pregnancy Outcome)
Must Supporttrue
54. Composition.section:motherPrenatal.entry:principalSourceOfPayment
Slice NameprincipalSourceOfPayment
Definition

The principal payer for this delivery

ShortPrincipal source of payment for this delivery
Control0..1
TypeReference(Coverage - Principal Payer for Delivery)
Must Supporttrue
56. Composition.section:motherPrenatal.entry:mothersWeightAtDelivery
Slice NamemothersWeightAtDelivery
Definition

The mother's weight at the time of delivery

ShortMother's weight at delivery
Control0..1
TypeReference(Observation - Mother Delivery Weight - Vital Records)
Must Supporttrue
58. Composition.section:motherPrenatal.entry:mothersHeight
Slice NamemothersHeight
Definition

The mother's height

ShortMother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Mother Height - Vital Records)
Must Supporttrue
60. Composition.section:motherPrenatal.entry:mothersPrepregnancyWeight
Slice NamemothersPrepregnancyWeight
Definition

The mother's prepregnancy weight

ShortMother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Mother Prepregnancy Weight - Vital Records)
Must Supporttrue
62. Composition.section:motherPrenatal.entry:motherReceivedWICFood
Slice NamemotherReceivedWICFood
Definition

Use of the Women, Infant's, and Children (WIC) nutritional program by the mother during the pregnancy.

ShortUse of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Mother Recieved WIC Food)
Must Supporttrue
64. Composition.section:motherPrenatal.entry:cigaretteSmokingBeforeDuringPregnancy
Slice NamecigaretteSmokingBeforeDuringPregnancy
Definition

The number of cigarettes or packs of cigarettes the mother smoked 3 months before and at various intervals during the pregnancy

ShortCigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..4
TypeReference(Observation - Cigarette Smoking Before and During Pregnancy)
Must Supporttrue
66. Composition.section:medicalHealthInformation
Slice NamemedicalHealthInformation
Definition

This section contains items from the Medical and Health Information section on the Live Birth Certificate.

ShortMedical and Health Information section on the Live Birth Certificate
Control0..1
Must Supporttrue
68. Composition.section:medicalHealthInformation.code
Definition

Clinical information

ShortClinical information
Control1..?
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;55752-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
70. Composition.section:medicalHealthInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.

ShortThe focus of this section is the mother
Control1..?
TypeReference(Patient - Mother - Vital Records)
Must Supporttrue
72. Composition.section:medicalHealthInformation.entry
Definition

Entries that are contained in the medical and health information section

ShortEntries that are contained in the medical and health information section
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
74. Composition.section:medicalHealthInformation.entry:pregnancyRiskFactors
Slice NamepregnancyRiskFactors
Definition

Selected medical risk factors of the mother during this pregnancy

ShortRisk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements.
TypeReference(Condition - Prepregnancy Diabetes - Vital Records, Condition - Gestational Diabetes - Vital Records, Condition - Prepregnancy Hypertension - Vital Records, Condition - Gestational Hypertension - Vital Records, Condition - Eclampsia Hypertension - Vital Records, Observation - Previous Preterm Birth - Vital Records, Procedure - Infertility Treatment - Vital Records, Procedure - Artificial Insemination - Vital Records, Procedure - Assisted Fertilization - Vital Records, Observation - Previous Cesarean - Vital Records, Observation - None Of Specified Pregnancy Risk Factors - Vital Records)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
76. Composition.section:medicalHealthInformation.entry:numberPreviousCesareans
Slice NamenumberPreviousCesareans
Definition

Number of previous cesarean deliveries.

ShortIf mother had a previous cesarean delivery, how many
Control0..1
TypeReference(Observation - Number of Previous Cesareans - Vital Records)
Must Supporttrue
78. Composition.section:medicalHealthInformation.entry:infectionsDuringPregnancy
Slice NameinfectionsDuringPregnancy
Definition

Selected infections that the mother had or was treated for during the course of this pregnancy

ShortInfections present and/or treated during this pregnancy
TypeReference(Condition - Infection Present During Pregnancy)
Must Supporttrue
80. Composition.section:medicalHealthInformation.entry:obstetricProcedures
Slice NameobstetricProcedures
Definition

Selected medical treatments or invasive/manipulative procedures performed during this pregnancy specifically for management of labor and delivery

ShortObstetric procedures
Control1..1
TypeReference(Procedure - Obstetric)
Must Supporttrue
82. Composition.section:medicalHealthInformation.entry:characteristicsLaborDelivery
Slice NamecharacteristicsLaborDelivery
Definition

Information about the course of labor and delivery

ShortCharacteristics of labor and delivery
TypeReference(Procedure - Induction of Labor, Procedure - Augmentation of Labor, Observation - Administration of Steroids for Fetal Lung Maturation, Observation - Antibiotics Administered During Labor, Condition - Chorioamnionitis, Procedure - Epidural or Spinal Anesthesia, Observation - None Of Specified Characteristics of Labor and Delivery)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
84. Composition.section:medicalHealthInformation.entry:fetalPresentation
Slice NamefetalPresentation
Definition

Fetal presentation at birth

ShortFetal presentation at birth
Control0..1
TypeReference(Observation - Fetal Presentation at Birth/Delivery)
Must Supporttrue
86. Composition.section:medicalHealthInformation.entry:finalRouteMethodDelivery
Slice NamefinalRouteMethodDelivery
Definition

Final route and method of delivery

ShortFinal route and method of delivery
Control0..1
TypeReference(Procedure - Final Route and Method of Delivery)
Must Supporttrue
88. Composition.section:medicalHealthInformation.entry:maternalMorbidity
Slice NamematernalMorbidity
Definition

Serious complications experienced by the mother associated with labor and delivery

ShortMaternal morbidity (complications associated with labor and delivery)
TypeReference(Procedure - Blood Transfusion, Condition - Perineal Laceration, Condition - Ruptured Uterus, Procedure - Unplanned Hysterectomy, Observation - ICU Admission, Observation - None Of Specified Maternal Morbidities)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
90. Composition.section:newbornInformation
Slice NamenewbornInformation
Definition

This section contains items from the newborn section on the Live Birth Certificate.

ShortNewborn section on the Live Birth Certificate
Control0..1
Must Supporttrue
92. Composition.section:newbornInformation.code
Definition

Newborn delivery information

ShortNewborn delivery information
Control1..?
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57075-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
94. Composition.section:newbornInformation.entry
Definition

Entries that are contained in the newborn section

ShortEntries that are contained in the newborn section
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
96. Composition.section:newbornInformation.entry:birthWeight
Slice NamebirthWeight
Definition

The weight of the infant/fetus at birth/delivery

ShortBirthweight
Control0..1
TypeReference(Observation - Birth Weight - Vital Records)
Must Supporttrue
98. Composition.section:newbornInformation.entry:gestationalAgeAtDelivery
Slice NamegestationalAgeAtDelivery
Definition

The obstetric estimate of the infant’s gestation in completed weeks based on the birth/delivery attendant’s final estimate of gestation which should be determined by all perinatal factors and assessments such as ultrasound, but not the neonatal exam

ShortObstetric estimate of gestation
Control0..1
TypeReference(Observation - Gestational Age at Delivery - Vital Records)
Must Supporttrue
100. Composition.section:newbornInformation.entry:ApgarScore
Slice NameApgarScore
Definition

The Apgar Score for the child.

ShortApgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used.
Control0..2
TypeReference(Observation - Apgar Score - Vital Records)
Must Supporttrue
102. Composition.section:newbornInformation.entry:numberLiveBirthsThisDelivery
Slice NamenumberLiveBirthsThisDelivery
ShortNumber of live births this delivery
Control0..1
TypeReference(Observation - Number of Live Births This Delivery - Vital Records)
Must Supporttrue
104. Composition.section:newbornInformation.entry:abnormalConditionsNewborn
Slice NameabnormalConditionsNewborn
Definition

Disorders or significant morbidity experienced by the newborn infant

ShortAbnormal conditions of the newborn
TypeReference(Procedure - Assisted Ventilation Following Delivery, Procedure - Assisted Ventilation More Than Six Hours, Observation - NICU Admission, Procedure - Surfactant Replacement Therapy, Procedure - Antibiotic for Suspected Neonatal Sepsis, Condition - Seizure, Observation - None Of Specified Abnormal Conditions of Newborn)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
106. Composition.section:newbornInformation.entry:congenitalAnomaliesNewborn
Slice NamecongenitalAnomaliesNewborn
Definition

Malformations of the newborn diagnosed prenatally or after delivery

ShortCongenital anomolies of the newborn
TypeReference(Condition - Congenital Anomaly of Newborn)
Must Supporttrue
108. Composition.section:newbornInformation.entry:infantLiving
Slice NameinfantLiving
Definition

Information on the infant's survival

ShortIs infant living at time of report?
Control0..1
TypeReference(Observation - Infant Living - Vital Records)
Must Supporttrue
110. Composition.section:newbornInformation.entry:infantBreastfedAtDischarge
Slice NameinfantBreastfedAtDischarge
Definition

Information on whether the infant is being breastfed at discharge from the hospital

ShortIs infant being breastfed at discharge?
Control0..1
TypeReference(Observation - Infant Breastfed at Discharge)
Must Supporttrue
112. Composition.section:motherInformation
Slice NamemotherInformation
Control0..1
Must Supporttrue
114. Composition.section:motherInformation.code
Definition

Mother's administrative information

ShortMother's administrative information
Control1..?
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92014-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
116. Composition.section:motherInformation.focus
Control1..?
TypeReference(Patient - Mother - Vital Records)
Must Supporttrue
118. Composition.section:motherInformation.entry
Control1..*
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ resolve()
120. Composition.section:motherInformation.entry:marriedDuringPregnancy
Slice NamemarriedDuringPregnancy
Definition

Was mother married at conception, at the time of birth, or at any time between conception and giving birth?

ShortMother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Mother Married During Pregnancy)
Must Supporttrue
122. Composition.section:motherInformation.entry:ssnRequestedForChild
Slice NamessnRequestedForChild
Definition

Was social security number requested for the child

ShortWas social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Social Security Number Requested For Child)
Must Supporttrue
124. Composition.section:motherInformation.entry:mothersEducation
Slice NamemothersEducation
Definition

Mother's education

ShortMother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Parent Education Level - Vital Records)
Must Supporttrue
126. Composition.section:fatherInformation
Slice NamefatherInformation
Definition

This section contains items from the father section on the Live Birth Certificate.

ShortFather section on the Live Birth Certificate
Control0..1
Must Supporttrue
128. Composition.section:fatherInformation.code
Definition

Father's administrative information

ShortFather's administrative information
Control1..?
Must Supporttrue
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92013-2&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
130. Composition.section:fatherInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the father.

ShortThe focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity.
Control1..?
TypeReference(RelatedPerson - Father Natural - Vital Records)
Must Supporttrue
132. Composition.section:fatherInformation.entry
Definition

Entries that are contained in the fatherInformation section

ShortEntries that are contained in the fatherInformation section
Control1..?
Must Supporttrue
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
134. Composition.section:fatherInformation.entry:paternityAcknowledgementSigned
Slice NamepaternityAcknowledgementSigned
Definition

Whether or not a paternity acknowledgement was signed by the father if the mother was not married at conception, at the time of birth, or at any time between conception and giving birth.

ShortPaternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Paternity Acknowledgement Signed)
Must Supporttrue
136. Composition.section:fatherInformation.entry:fathersEducation
Slice NamefathersEducation
Definition

Father's education

ShortFather's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Control0..1
TypeReference(Observation - Parent Education Level - Vital Records)
Must Supporttrue
138. Composition.section:patientsQuestionnaireResponse
Slice NamepatientsQuestionnaireResponse
ShortOptional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate
Control0..1
140. Composition.section:patientsQuestionnaireResponse.code
ShortQuestionnaire response Document
Control1..?
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;74465-6&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
142. Composition.section:patientsQuestionnaireResponse.entry
ShortQuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report
Control1..1
TypeReference(QuestionnaireResponse)

Guidance on how to interpret the contents of this table can be found here

0. Composition
Definition

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

ShortProvider Live Birth ReportA set of resources composed into a single coherent clinical statement with clinical attestation
Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Composition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Composition.extension
Definition

An Extension


May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortExtensionAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control10..*
TypeExtension
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Composition.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
6. Composition.extension:liveBirthCertificateNumber
Slice NameliveBirthCertificateNumber
Definition

An Extension

ShortBirth Number
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Live Birth Certificate Number) (Extension Type: Identifier)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. Composition.extension:liveBirthLocalFileNumber
Slice NameliveBirthLocalFileNumber
Definition

An Extension

ShortLocal File No.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Live Birth Local File Number) (Extension Type: Identifier)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. Composition.extension:dateFiledByRegistrar
Slice NamedateFiledByRegistrar
Definition

An Extension

ShortDate filed by registrar
Control1..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Date Filed by Registrar) (Extension Type: dateTime)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. Composition.extension:replacementStatus
Slice NamereplacementStatus
Definition

An Extension

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Replacement Status) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
14. Composition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. Composition.status
Definition

In the case of a live birth sent in error, a status of 'entered-in-error' must be set.


The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

ShortIn the case of a live birth sent in error, a status of 'entered-in-error' must be set.preliminary | final | amended | entered-in-error
Comments

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

Control1..1
BindingThe codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1

The workflow/clinical status of the composition.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Composition.type
Definition

U.S. standard certificate of live birth - 2003 revision


Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.

ShortU.S. standard certificate of live birth - 2003 revisionKind of composition (LOINC if possible)
Comments

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Control1..1
BindingThe codes SHOULD be taken from FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes

Type of a composition.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Key metadata element describing the composition, used in searching/filtering.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;68998-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Composition.subject
Definition

The subject of the composition as a whole is the newborn baby. Different sections in the composition have different focus (e.g.: the mother).


Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

ShortThe subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name.Who and/or what the composition is about
Comments

For clinical documents, this is usually the patient.

Control10..1
TypeReference(Patient - Child - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Composition.encounter
Definition

The Encounter for the Composition is the newborn's birth encounter. This Encounter links to the mother's encounter by the Encounter.partOf data element.


Describes the clinical encounter or type of care this documentation is associated with.

ShortThe Encounter for the Composition is the newborn's birth encounter.Context of the Composition
Control0..1
TypeReference(Encounter - Birth, Encounter)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Provides context for the composition and supports searching.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Composition.encounter.extension
Definition

An Extension


May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortThe Encounter is the maternity encounter.
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..1
TypeExtension(Extension - Encounter Maternity Reference) (Extension Type: Reference(Encounter - Maternity))
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
26. Composition.date
Definition

The composition editing time, when the composition was last logically changed by the author.

ShortDate report completedComposition editing time
Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Composition.author
Definition

Name and title of person completing the report. May be, but need not be, the same as the attendant at delivery.


Identifies who is responsible for the information in the composition, not necessarily who typed it in.

ShortThe author is the person who verifies/approves the accuracy of the data to be sent to the vital records system.Who and/or what authored the composition
Control1..1*
TypeReference(Practitioner - Vital Records, Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Composition.title
Definition

Official human-readable label for the composition.

ShortHuman Readable name/title
Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Composition.section
Definition

The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Various administrative and demographic data in the Birth Certificate are contained in other locations in the Composition, such as the Patient and Encounter profiles.


The root of the sections that make up the composition.

ShortThe Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate.Composition is broken into sections
Control10..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ code
34. Composition.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
36. Composition.section:motherPrenatal
Slice NamemotherPrenatal
Definition

This section contains items from the Mother (prenatal) on theLive Birth Certificate.


The root of the sections that make up the composition.

ShortMother (prenatal) section on the Live Birth CertificateComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
38. Composition.section:motherPrenatal.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
40. Composition.section:motherPrenatal.code
Definition

Prenatal records


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortPrenatal recordsClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57073-9&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Composition.section:motherPrenatal.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.


The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortThe focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity.Who/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control10..1
TypeReference(Patient - Mother - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Composition.section:motherPrenatal.entry
Definition

Entries that are contained in the Mother Prenatal section


A reference to the actual resource from which the narrative in the section is derived.

ShortEntries that are contained in the Mother Prenatal sectionA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
46. Composition.section:motherPrenatal.entry:plannedToDeliverAtHome
Slice NameplannedToDeliverAtHome
Definition

Planned to deliver at home


A reference to the actual resource from which the narrative in the section is derived.

ShortPlanned to deliver at homeA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Planned to Deliver at Home, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Composition.section:motherPrenatal.entry:firstPrenatalCareVisit
Slice NamefirstPrenatalCareVisit
Definition

Date that mother had her first prenatal care visit.


A reference to the actual resource from which the narrative in the section is derived.

ShortFirst prenatal care visitA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of First Prenatal Care Visit, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Composition.section:motherPrenatal.entry:numberPrenatalCareVisits
Slice NamenumberPrenatalCareVisits
Definition

Those visits which are listed in the mother's prenatal care and/or facility records.


A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of prenatal care visitsA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Prenatal Visits - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Composition.section:motherPrenatal.entry:dateLastNormalMenses
Slice NamedateLastNormalMenses
Definition

Date that the mother's last normal menses began. This item is used to compute the gestational age of the infant.


A reference to the actual resource from which the narrative in the section is derived.

ShortDate last normal menses beganA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Last Menstrual Period - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Composition.section:motherPrenatal.entry:numberNowLiving
Slice NamenumberNowLiving
Definition

The pregnancy history of the mother with respect to previous children born alive


A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of previous live births now livingA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Births Now Living - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Composition.section:motherPrenatal.entry:numberNowDead
Slice NamenumberNowDead
Definition

The pregnancy history of the mother with respect to previous children born alive


A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of previous live births now deadA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Births Now Dead - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Composition.section:motherPrenatal.entry:dateLastLiveBirth
Slice NamedateLastLiveBirth
Definition

The pregnancy history of the mother with respect to previous children born alive


A reference to the actual resource from which the narrative in the section is derived.

ShortDate of last live birthA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of Last Live Birth, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Composition.section:motherPrenatal.entry:numberOtherOutcomes
Slice NamenumberOtherOutcomes
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).


A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of other pregnancy outcomesA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Other Pregnancy Outcomes - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Composition.section:motherPrenatal.entry:dateLastOtherOutcome
Slice NamedateLastOtherOutcome
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).


A reference to the actual resource from which the narrative in the section is derived.

ShortDate of last other pregnancy outcomeA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of Last Other Pregnancy Outcome, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Composition.section:motherPrenatal.entry:principalSourceOfPayment
Slice NameprincipalSourceOfPayment
Definition

The principal payer for this delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortPrincipal source of payment for this deliveryA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Coverage - Principal Payer for Delivery, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. Composition.section:motherPrenatal.entry:mothersWeightAtDelivery
Slice NamemothersWeightAtDelivery
Definition

The mother's weight at the time of delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortMother's weight at deliveryA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Delivery Weight - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Composition.section:motherPrenatal.entry:mothersHeight
Slice NamemothersHeight
Definition

The mother's height


A reference to the actual resource from which the narrative in the section is derived.

ShortMother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Height - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Composition.section:motherPrenatal.entry:mothersPrepregnancyWeight
Slice NamemothersPrepregnancyWeight
Definition

The mother's prepregnancy weight


A reference to the actual resource from which the narrative in the section is derived.

ShortMother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Prepregnancy Weight - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Composition.section:motherPrenatal.entry:motherReceivedWICFood
Slice NamemotherReceivedWICFood
Definition

Use of the Women, Infant's, and Children (WIC) nutritional program by the mother during the pregnancy.


A reference to the actual resource from which the narrative in the section is derived.

ShortUse of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Recieved WIC Food, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Composition.section:motherPrenatal.entry:cigaretteSmokingBeforeDuringPregnancy
Slice NamecigaretteSmokingBeforeDuringPregnancy
Definition

The number of cigarettes or packs of cigarettes the mother smoked 3 months before and at various intervals during the pregnancy


A reference to the actual resource from which the narrative in the section is derived.

ShortCigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..4*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Cigarette Smoking Before and During Pregnancy, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Composition.section:medicalHealthInformation
Slice NamemedicalHealthInformation
Definition

This section contains items from the Medical and Health Information section on the Live Birth Certificate.


The root of the sections that make up the composition.

ShortMedical and Health Information section on the Live Birth CertificateComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
78. Composition.section:medicalHealthInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. Composition.section:medicalHealthInformation.code
Definition

Clinical information


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClinical informationClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;55752-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Composition.section:medicalHealthInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.


The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortThe focus of this section is the motherWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control10..1
TypeReference(Patient - Mother - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Composition.section:medicalHealthInformation.entry
Definition

Entries that are contained in the medical and health information section


A reference to the actual resource from which the narrative in the section is derived.

ShortEntries that are contained in the medical and health information sectionA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
86. Composition.section:medicalHealthInformation.entry:pregnancyRiskFactors
Slice NamepregnancyRiskFactors
Definition

Selected medical risk factors of the mother during this pregnancy


A reference to the actual resource from which the narrative in the section is derived.

ShortRisk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Prepregnancy Diabetes - Vital Records, Condition - Gestational Diabetes - Vital Records, Condition - Prepregnancy Hypertension - Vital Records, Condition - Gestational Hypertension - Vital Records, Condition - Eclampsia Hypertension - Vital Records, Observation - Previous Preterm Birth - Vital Records, Procedure - Infertility Treatment - Vital Records, Procedure - Artificial Insemination - Vital Records, Procedure - Assisted Fertilization - Vital Records, Observation - Previous Cesarean - Vital Records, Observation - None Of Specified Pregnancy Risk Factors - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Composition.section:medicalHealthInformation.entry:numberPreviousCesareans
Slice NamenumberPreviousCesareans
Definition

Number of previous cesarean deliveries.


A reference to the actual resource from which the narrative in the section is derived.

ShortIf mother had a previous cesarean delivery, how manyA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Previous Cesareans - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Composition.section:medicalHealthInformation.entry:infectionsDuringPregnancy
Slice NameinfectionsDuringPregnancy
Definition

Selected infections that the mother had or was treated for during the course of this pregnancy


A reference to the actual resource from which the narrative in the section is derived.

ShortInfections present and/or treated during this pregnancyA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Infection Present During Pregnancy, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. Composition.section:medicalHealthInformation.entry:obstetricProcedures
Slice NameobstetricProcedures
Definition

Selected medical treatments or invasive/manipulative procedures performed during this pregnancy specifically for management of labor and delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortObstetric proceduresA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..1*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Obstetric, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Composition.section:medicalHealthInformation.entry:characteristicsLaborDelivery
Slice NamecharacteristicsLaborDelivery
Definition

Information about the course of labor and delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortCharacteristics of labor and deliveryA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Induction of Labor, Procedure - Augmentation of Labor, Observation - Administration of Steroids for Fetal Lung Maturation, Observation - Antibiotics Administered During Labor, Condition - Chorioamnionitis, Procedure - Epidural or Spinal Anesthesia, Observation - None Of Specified Characteristics of Labor and Delivery, Resource)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Composition.section:medicalHealthInformation.entry:fetalPresentation
Slice NamefetalPresentation
Definition

Fetal presentation at birth


A reference to the actual resource from which the narrative in the section is derived.

ShortFetal presentation at birthA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Fetal Presentation at Birth/Delivery, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Composition.section:medicalHealthInformation.entry:finalRouteMethodDelivery
Slice NamefinalRouteMethodDelivery
Definition

Final route and method of delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortFinal route and method of deliveryA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Final Route and Method of Delivery, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Composition.section:medicalHealthInformation.entry:maternalMorbidity
Slice NamematernalMorbidity
Definition

Serious complications experienced by the mother associated with labor and delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortMaternal morbidity (complications associated with labor and delivery)A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Blood Transfusion, Condition - Perineal Laceration, Condition - Ruptured Uterus, Procedure - Unplanned Hysterectomy, Observation - ICU Admission, Observation - None Of Specified Maternal Morbidities, Resource)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. Composition.section:newbornInformation
Slice NamenewbornInformation
Definition

This section contains items from the newborn section on the Live Birth Certificate.


The root of the sections that make up the composition.

ShortNewborn section on the Live Birth CertificateComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
104. Composition.section:newbornInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
106. Composition.section:newbornInformation.code
Definition

Newborn delivery information


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortNewborn delivery informationClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57075-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. Composition.section:newbornInformation.entry
Definition

Entries that are contained in the newborn section


A reference to the actual resource from which the narrative in the section is derived.

ShortEntries that are contained in the newborn sectionA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
110. Composition.section:newbornInformation.entry:birthWeight
Slice NamebirthWeight
Definition

The weight of the infant/fetus at birth/delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortBirthweightA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Birth Weight - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Composition.section:newbornInformation.entry:gestationalAgeAtDelivery
Slice NamegestationalAgeAtDelivery
Definition

The obstetric estimate of the infant’s gestation in completed weeks based on the birth/delivery attendant’s final estimate of gestation which should be determined by all perinatal factors and assessments such as ultrasound, but not the neonatal exam


A reference to the actual resource from which the narrative in the section is derived.

ShortObstetric estimate of gestationA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Gestational Age at Delivery - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. Composition.section:newbornInformation.entry:ApgarScore
Slice NameApgarScore
Definition

The Apgar Score for the child.


A reference to the actual resource from which the narrative in the section is derived.

ShortApgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..2*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Apgar Score - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. Composition.section:newbornInformation.entry:numberLiveBirthsThisDelivery
Slice NamenumberLiveBirthsThisDelivery
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of live births this deliveryA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Live Births This Delivery - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Composition.section:newbornInformation.entry:abnormalConditionsNewborn
Slice NameabnormalConditionsNewborn
Definition

Disorders or significant morbidity experienced by the newborn infant


A reference to the actual resource from which the narrative in the section is derived.

ShortAbnormal conditions of the newbornA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Assisted Ventilation Following Delivery, Procedure - Assisted Ventilation More Than Six Hours, Observation - NICU Admission, Procedure - Surfactant Replacement Therapy, Procedure - Antibiotic for Suspected Neonatal Sepsis, Condition - Seizure, Observation - None Of Specified Abnormal Conditions of Newborn, Resource)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. Composition.section:newbornInformation.entry:congenitalAnomaliesNewborn
Slice NamecongenitalAnomaliesNewborn
Definition

Malformations of the newborn diagnosed prenatally or after delivery


A reference to the actual resource from which the narrative in the section is derived.

ShortCongenital anomolies of the newbornA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Congenital Anomaly of Newborn, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. Composition.section:newbornInformation.entry:infantLiving
Slice NameinfantLiving
Definition

Information on the infant's survival


A reference to the actual resource from which the narrative in the section is derived.

ShortIs infant living at time of report?A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Infant Living - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. Composition.section:newbornInformation.entry:infantBreastfedAtDischarge
Slice NameinfantBreastfedAtDischarge
Definition

Information on whether the infant is being breastfed at discharge from the hospital


A reference to the actual resource from which the narrative in the section is derived.

ShortIs infant being breastfed at discharge?A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Infant Breastfed at Discharge, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. Composition.section:motherInformation
Slice NamemotherInformation
Definition

The root of the sections that make up the composition.

ShortComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
128. Composition.section:motherInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
130. Composition.section:motherInformation.code
Definition

Mother's administrative information


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortMother's administrative informationClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92014-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
132. Composition.section:motherInformation.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control10..1
TypeReference(Patient - Mother - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
134. Composition.section:motherInformation.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ resolve()
136. Composition.section:motherInformation.entry:marriedDuringPregnancy
Slice NamemarriedDuringPregnancy
Definition

Was mother married at conception, at the time of birth, or at any time between conception and giving birth?


A reference to the actual resource from which the narrative in the section is derived.

ShortMother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Married During Pregnancy, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. Composition.section:motherInformation.entry:ssnRequestedForChild
Slice NamessnRequestedForChild
Definition

Was social security number requested for the child


A reference to the actual resource from which the narrative in the section is derived.

ShortWas social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Social Security Number Requested For Child, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. Composition.section:motherInformation.entry:mothersEducation
Slice NamemothersEducation
Definition

Mother's education


A reference to the actual resource from which the narrative in the section is derived.

ShortMother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Parent Education Level - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. Composition.section:fatherInformation
Slice NamefatherInformation
Definition

This section contains items from the father section on the Live Birth Certificate.


The root of the sections that make up the composition.

ShortFather section on the Live Birth CertificateComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
144. Composition.section:fatherInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
146. Composition.section:fatherInformation.code
Definition

Father's administrative information


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortFather's administrative informationClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92013-2&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. Composition.section:fatherInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the father.


The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortThe focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity.Who/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control10..1
TypeReference(RelatedPerson - Father Natural - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. Composition.section:fatherInformation.entry
Definition

Entries that are contained in the fatherInformation section


A reference to the actual resource from which the narrative in the section is derived.

ShortEntries that are contained in the fatherInformation sectionA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
152. Composition.section:fatherInformation.entry:paternityAcknowledgementSigned
Slice NamepaternityAcknowledgementSigned
Definition

Whether or not a paternity acknowledgement was signed by the father if the mother was not married at conception, at the time of birth, or at any time between conception and giving birth.


A reference to the actual resource from which the narrative in the section is derived.

ShortPaternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Paternity Acknowledgement Signed, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
154. Composition.section:fatherInformation.entry:fathersEducation
Slice NamefathersEducation
Definition

Father's education


A reference to the actual resource from which the narrative in the section is derived.

ShortFather's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.A reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1*
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Parent Education Level - Vital Records, Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
156. Composition.section:patientsQuestionnaireResponse
Slice NamepatientsQuestionnaireResponse
Definition

The root of the sections that make up the composition.

ShortOptional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth CertificateComposition is broken into sections
Control0..1*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
158. Composition.section:patientsQuestionnaireResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
160. Composition.section:patientsQuestionnaireResponse.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortQuestionnaire response DocumentClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;74465-6&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. Composition.section:patientsQuestionnaireResponse.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortQuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death ReportA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..1*
This element is affected by the following invariants: cmp-2
TypeReference(QuestionnaireResponse, Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Composition
Definition

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

ShortProvider Live Birth Report
Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Composition.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Composition.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Composition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Composition.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages: A human language.
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Composition.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Composition.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Composition.extension
Definition

An Extension

ShortExtension
Control1..*
TypeExtension
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Composition.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
16. Composition.extension:liveBirthCertificateNumber
Slice NameliveBirthCertificateNumber
Definition

An Extension

ShortBirth Number
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Live Birth Certificate Number) (Extension Type: Identifier)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Composition.extension:liveBirthLocalFileNumber
Slice NameliveBirthLocalFileNumber
Definition

An Extension

ShortLocal File No.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Live Birth Local File Number) (Extension Type: Identifier)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
20. Composition.extension:dateFiledByRegistrar
Slice NamedateFiledByRegistrar
Definition

An Extension

ShortDate filed by registrar
Control1..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Date Filed by Registrar) (Extension Type: dateTime)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
22. Composition.extension:replacementStatus
Slice NamereplacementStatus
Definition

An Extension

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Extension - Replacement Status) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
24. Composition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
26. Composition.identifier
Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

ShortVersion-independent identifier for the Composition
Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Composition.status
Definition

In the case of a live birth sent in error, a status of 'entered-in-error' must be set.

ShortIn the case of a live birth sent in error, a status of 'entered-in-error' must be set.
Comments

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Control1..1
BindingThe codes SHALL be taken from CompositionStatus: The workflow/clinical status of the composition.
Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Composition.type
Definition

U.S. standard certificate of live birth - 2003 revision

ShortU.S. standard certificate of live birth - 2003 revision
Comments

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Control1..1
BindingThe codes SHOULD be taken from FHIRDocumentTypeCodes: Type of a composition.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Key metadata element describing the composition, used in searching/filtering.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;68998-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Composition.category
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortCategorization of Composition
Comments

This is a metadata field from XDS/MHD.

Control0..*
BindingFor example codes, see DocumentClassValueSet: High-level kind of a clinical document at a macro level.
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Composition.subject
Definition

The subject of the composition as a whole is the newborn baby. Different sections in the composition have different focus (e.g.: the mother).

ShortThe subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name.
Comments

For clinical documents, this is usually the patient.

Control1..1
TypeReference(Patient - Child - Vital Records)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Composition.encounter
Definition

The Encounter for the Composition is the newborn's birth encounter. This Encounter links to the mother's encounter by the Encounter.partOf data element.

ShortThe Encounter for the Composition is the newborn's birth encounter.
Control0..1
TypeReference(Encounter - Birth)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Provides context for the composition and supports searching.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Composition.encounter.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
40. Composition.encounter.extension
Definition

An Extension

ShortThe Encounter is the maternity encounter.
Control0..1
TypeExtension(Extension - Encounter Maternity Reference) (Extension Type: Reference(Encounter - Maternity))
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
42. Composition.encounter.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control0..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Composition.encounter.type
Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

ShortType the reference refers to (e.g. "Patient")
Comments

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Control0..1
BindingUnless not suitable, these codes SHALL be taken from ResourceType: Aa resource (or, for logical models, the URI of the logical model).
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Composition.encounter.identifier
Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

ShortLogical reference, when literal reference is not known
Comments

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Composition.encounter.display
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

ShortText alternative for the resource
Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Composition.date
Definition

The composition editing time, when the composition was last logically changed by the author.

ShortDate report completed
Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Composition.author
Definition

Name and title of person completing the report. May be, but need not be, the same as the attendant at delivery.

ShortThe author is the person who verifies/approves the accuracy of the data to be sent to the vital records system.
Control1..1
TypeReference(Practitioner - Vital Records)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Composition.title
Definition

Official human-readable label for the composition.

ShortHuman Readable name/title
Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Composition.confidentiality
Definition

The code specifying the level of confidentiality of the Composition.

ShortAs defined by affinity domain
Comments

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Control0..1
BindingThe codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26): Codes specifying the level of confidentiality of the composition.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Composition.attester
Definition

A participant who has attested to the accuracy of the composition/document.

ShortAttests to accuracy of composition
Comments

Only list each attester once.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Identifies responsibility for the accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Composition.attester.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
62. Composition.attester.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. Composition.attester.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. Composition.attester.mode
Definition

The type of attestation the authenticator offers.

Shortpersonal | professional | legal | official
Control1..1
BindingThe codes SHALL be taken from CompositionAttestationMode: The way in which a person authenticated a composition.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Indicates the level of authority of the attestation.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Composition.attester.time
Definition

When the composition was attested by the party.

ShortWhen the composition was attested
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Composition.attester.party
Definition

Who attested the composition in the specified way.

ShortWho attested the composition
Control0..1
TypeReference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Composition.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

ShortOrganization which maintains the composition
Comments

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Control0..1
TypeReference(Organization)
Is Modifierfalse
Summarytrue
Requirements

Identifies where to go to find the current version, where to report issues, etc.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Composition.relatesTo
Definition

Relationships that this composition has with other compositions or documents that already exist.

ShortRelationships to other compositions/documents
Comments

A document is a version specific composition.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Composition.relatesTo.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
78. Composition.relatesTo.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. Composition.relatesTo.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. Composition.relatesTo.code
Definition

The type of relationship that this composition has with anther composition or document.

Shortreplaces | transforms | signs | appends
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Control1..1
BindingThe codes SHALL be taken from DocumentRelationshipType: The type of relationship between documents.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Composition.relatesTo.target[x]
Definition

The target composition/document of this relationship.

ShortTarget of the relationship
Control1..1
TypeChoice of: Identifier, Reference(Composition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Composition.event
Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

ShortThe clinical service(s) being documented
Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Composition.event.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
90. Composition.event.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. Composition.event.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. Composition.event.code
Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

ShortCode(s) that apply to the event being documented
Comments

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

Control0..*
BindingFor example codes, see v3 Code System ActCode: This list of codes represents the main clinical acts being documented.
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Composition.event.period
Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

ShortThe period covered by the documentation
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Composition.event.detail
Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

ShortThe event(s) being documented
Control0..*
TypeReference(Resource)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Composition.section
Definition

The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Various administrative and demographic data in the Birth Certificate are contained in other locations in the Composition, such as the Patient and Encounter profiles.

ShortThe Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate.
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ code
102. Composition.section.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
104. Composition.section.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
106. Composition.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
108. Composition.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Composition.section.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control0..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Composition.section.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. Composition.section.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. Composition.section.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Composition.section.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. Composition.section.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. Composition.section.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. Composition.section.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. Composition.section.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. Composition.section:motherPrenatal
Slice NamemotherPrenatal
Definition

This section contains items from the Mother (prenatal) on theLive Birth Certificate.

ShortMother (prenatal) section on the Live Birth Certificate
Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. Composition.section:motherPrenatal.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
132. Composition.section:motherPrenatal.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
134. Composition.section:motherPrenatal.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
136. Composition.section:motherPrenatal.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. Composition.section:motherPrenatal.code
Definition

Prenatal records

ShortPrenatal records
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57073-9&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. Composition.section:motherPrenatal.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. Composition.section:motherPrenatal.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.

ShortThe focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity.
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control1..1
TypeReference(Patient - Mother - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
144. Composition.section:motherPrenatal.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. Composition.section:motherPrenatal.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. Composition.section:motherPrenatal.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. Composition.section:motherPrenatal.entry
Definition

Entries that are contained in the Mother Prenatal section

ShortEntries that are contained in the Mother Prenatal section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
152. Composition.section:motherPrenatal.entry:plannedToDeliverAtHome
Slice NameplannedToDeliverAtHome
Definition

Planned to deliver at home

ShortPlanned to deliver at home
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Planned to Deliver at Home)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
154. Composition.section:motherPrenatal.entry:firstPrenatalCareVisit
Slice NamefirstPrenatalCareVisit
Definition

Date that mother had her first prenatal care visit.

ShortFirst prenatal care visit
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of First Prenatal Care Visit)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
156. Composition.section:motherPrenatal.entry:numberPrenatalCareVisits
Slice NamenumberPrenatalCareVisits
Definition

Those visits which are listed in the mother's prenatal care and/or facility records.

ShortNumber of prenatal care visits
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Prenatal Visits - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. Composition.section:motherPrenatal.entry:dateLastNormalMenses
Slice NamedateLastNormalMenses
Definition

Date that the mother's last normal menses began. This item is used to compute the gestational age of the infant.

ShortDate last normal menses began
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Last Menstrual Period - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
160. Composition.section:motherPrenatal.entry:numberNowLiving
Slice NamenumberNowLiving
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortNumber of previous live births now living
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Births Now Living - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. Composition.section:motherPrenatal.entry:numberNowDead
Slice NamenumberNowDead
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortNumber of previous live births now dead
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Births Now Dead - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
164. Composition.section:motherPrenatal.entry:dateLastLiveBirth
Slice NamedateLastLiveBirth
Definition

The pregnancy history of the mother with respect to previous children born alive

ShortDate of last live birth
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of Last Live Birth)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
166. Composition.section:motherPrenatal.entry:numberOtherOutcomes
Slice NamenumberOtherOutcomes
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).

ShortNumber of other pregnancy outcomes
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Other Pregnancy Outcomes - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
168. Composition.section:motherPrenatal.entry:dateLastOtherOutcome
Slice NamedateLastOtherOutcome
Definition

The pregnancy history of the mother with respect to other pregnancy outcomes (included pregnancy losses of any gestational age, e.g., spontaneous or induced losses or ectopic pregnancies).

ShortDate of last other pregnancy outcome
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Date of Last Other Pregnancy Outcome)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
170. Composition.section:motherPrenatal.entry:principalSourceOfPayment
Slice NameprincipalSourceOfPayment
Definition

The principal payer for this delivery

ShortPrincipal source of payment for this delivery
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Coverage - Principal Payer for Delivery)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
172. Composition.section:motherPrenatal.entry:mothersWeightAtDelivery
Slice NamemothersWeightAtDelivery
Definition

The mother's weight at the time of delivery

ShortMother's weight at delivery
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Delivery Weight - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
174. Composition.section:motherPrenatal.entry:mothersHeight
Slice NamemothersHeight
Definition

The mother's height

ShortMother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Height - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. Composition.section:motherPrenatal.entry:mothersPrepregnancyWeight
Slice NamemothersPrepregnancyWeight
Definition

The mother's prepregnancy weight

ShortMother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Prepregnancy Weight - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
178. Composition.section:motherPrenatal.entry:motherReceivedWICFood
Slice NamemotherReceivedWICFood
Definition

Use of the Women, Infant's, and Children (WIC) nutritional program by the mother during the pregnancy.

ShortUse of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Recieved WIC Food)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
180. Composition.section:motherPrenatal.entry:cigaretteSmokingBeforeDuringPregnancy
Slice NamecigaretteSmokingBeforeDuringPregnancy
Definition

The number of cigarettes or packs of cigarettes the mother smoked 3 months before and at various intervals during the pregnancy

ShortCigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..4
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Cigarette Smoking Before and During Pregnancy)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
182. Composition.section:motherPrenatal.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. Composition.section:motherPrenatal.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
186. Composition.section:medicalHealthInformation
Slice NamemedicalHealthInformation
Definition

This section contains items from the Medical and Health Information section on the Live Birth Certificate.

ShortMedical and Health Information section on the Live Birth Certificate
Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
188. Composition.section:medicalHealthInformation.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
190. Composition.section:medicalHealthInformation.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
192. Composition.section:medicalHealthInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
194. Composition.section:medicalHealthInformation.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
196. Composition.section:medicalHealthInformation.code
Definition

Clinical information

ShortClinical information
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;55752-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
198. Composition.section:medicalHealthInformation.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
200. Composition.section:medicalHealthInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the mother.

ShortThe focus of this section is the mother
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control1..1
TypeReference(Patient - Mother - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
202. Composition.section:medicalHealthInformation.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
204. Composition.section:medicalHealthInformation.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
206. Composition.section:medicalHealthInformation.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
208. Composition.section:medicalHealthInformation.entry
Definition

Entries that are contained in the medical and health information section

ShortEntries that are contained in the medical and health information section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
210. Composition.section:medicalHealthInformation.entry:pregnancyRiskFactors
Slice NamepregnancyRiskFactors
Definition

Selected medical risk factors of the mother during this pregnancy

ShortRisk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Prepregnancy Diabetes - Vital Records, Condition - Gestational Diabetes - Vital Records, Condition - Prepregnancy Hypertension - Vital Records, Condition - Gestational Hypertension - Vital Records, Condition - Eclampsia Hypertension - Vital Records, Observation - Previous Preterm Birth - Vital Records, Procedure - Infertility Treatment - Vital Records, Procedure - Artificial Insemination - Vital Records, Procedure - Assisted Fertilization - Vital Records, Observation - Previous Cesarean - Vital Records, Observation - None Of Specified Pregnancy Risk Factors - Vital Records)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
212. Composition.section:medicalHealthInformation.entry:numberPreviousCesareans
Slice NamenumberPreviousCesareans
Definition

Number of previous cesarean deliveries.

ShortIf mother had a previous cesarean delivery, how many
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Previous Cesareans - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
214. Composition.section:medicalHealthInformation.entry:infectionsDuringPregnancy
Slice NameinfectionsDuringPregnancy
Definition

Selected infections that the mother had or was treated for during the course of this pregnancy

ShortInfections present and/or treated during this pregnancy
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Infection Present During Pregnancy)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
216. Composition.section:medicalHealthInformation.entry:obstetricProcedures
Slice NameobstetricProcedures
Definition

Selected medical treatments or invasive/manipulative procedures performed during this pregnancy specifically for management of labor and delivery

ShortObstetric procedures
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..1
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Obstetric)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
218. Composition.section:medicalHealthInformation.entry:characteristicsLaborDelivery
Slice NamecharacteristicsLaborDelivery
Definition

Information about the course of labor and delivery

ShortCharacteristics of labor and delivery
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Induction of Labor, Procedure - Augmentation of Labor, Observation - Administration of Steroids for Fetal Lung Maturation, Observation - Antibiotics Administered During Labor, Condition - Chorioamnionitis, Procedure - Epidural or Spinal Anesthesia, Observation - None Of Specified Characteristics of Labor and Delivery)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
220. Composition.section:medicalHealthInformation.entry:fetalPresentation
Slice NamefetalPresentation
Definition

Fetal presentation at birth

ShortFetal presentation at birth
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Fetal Presentation at Birth/Delivery)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
222. Composition.section:medicalHealthInformation.entry:finalRouteMethodDelivery
Slice NamefinalRouteMethodDelivery
Definition

Final route and method of delivery

ShortFinal route and method of delivery
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Final Route and Method of Delivery)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
224. Composition.section:medicalHealthInformation.entry:maternalMorbidity
Slice NamematernalMorbidity
Definition

Serious complications experienced by the mother associated with labor and delivery

ShortMaternal morbidity (complications associated with labor and delivery)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Blood Transfusion, Condition - Perineal Laceration, Condition - Ruptured Uterus, Procedure - Unplanned Hysterectomy, Observation - ICU Admission, Observation - None Of Specified Maternal Morbidities)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
226. Composition.section:medicalHealthInformation.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
228. Composition.section:medicalHealthInformation.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
230. Composition.section:newbornInformation
Slice NamenewbornInformation
Definition

This section contains items from the newborn section on the Live Birth Certificate.

ShortNewborn section on the Live Birth Certificate
Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
232. Composition.section:newbornInformation.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
234. Composition.section:newbornInformation.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
236. Composition.section:newbornInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
238. Composition.section:newbornInformation.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
240. Composition.section:newbornInformation.code
Definition

Newborn delivery information

ShortNewborn delivery information
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;57075-4&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
242. Composition.section:newbornInformation.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
244. Composition.section:newbornInformation.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
246. Composition.section:newbornInformation.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
248. Composition.section:newbornInformation.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
250. Composition.section:newbornInformation.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
252. Composition.section:newbornInformation.entry
Definition

Entries that are contained in the newborn section

ShortEntries that are contained in the newborn section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
254. Composition.section:newbornInformation.entry:birthWeight
Slice NamebirthWeight
Definition

The weight of the infant/fetus at birth/delivery

ShortBirthweight
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Birth Weight - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
256. Composition.section:newbornInformation.entry:gestationalAgeAtDelivery
Slice NamegestationalAgeAtDelivery
Definition

The obstetric estimate of the infant’s gestation in completed weeks based on the birth/delivery attendant’s final estimate of gestation which should be determined by all perinatal factors and assessments such as ultrasound, but not the neonatal exam

ShortObstetric estimate of gestation
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Gestational Age at Delivery - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
258. Composition.section:newbornInformation.entry:ApgarScore
Slice NameApgarScore
Definition

The Apgar Score for the child.

ShortApgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..2
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Apgar Score - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
260. Composition.section:newbornInformation.entry:numberLiveBirthsThisDelivery
Slice NamenumberLiveBirthsThisDelivery
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortNumber of live births this delivery
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Number of Live Births This Delivery - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
262. Composition.section:newbornInformation.entry:abnormalConditionsNewborn
Slice NameabnormalConditionsNewborn
Definition

Disorders or significant morbidity experienced by the newborn infant

ShortAbnormal conditions of the newborn
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Procedure - Assisted Ventilation Following Delivery, Procedure - Assisted Ventilation More Than Six Hours, Observation - NICU Admission, Procedure - Surfactant Replacement Therapy, Procedure - Antibiotic for Suspected Neonatal Sepsis, Condition - Seizure, Observation - None Of Specified Abnormal Conditions of Newborn)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
264. Composition.section:newbornInformation.entry:congenitalAnomaliesNewborn
Slice NamecongenitalAnomaliesNewborn
Definition

Malformations of the newborn diagnosed prenatally or after delivery

ShortCongenital anomolies of the newborn
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Condition - Congenital Anomaly of Newborn)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
266. Composition.section:newbornInformation.entry:infantLiving
Slice NameinfantLiving
Definition

Information on the infant's survival

ShortIs infant living at time of report?
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Infant Living - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
268. Composition.section:newbornInformation.entry:infantBreastfedAtDischarge
Slice NameinfantBreastfedAtDischarge
Definition

Information on whether the infant is being breastfed at discharge from the hospital

ShortIs infant being breastfed at discharge?
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Infant Breastfed at Discharge)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
270. Composition.section:newbornInformation.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
272. Composition.section:newbornInformation.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
274. Composition.section:motherInformation
Slice NamemotherInformation
Definition

The root of the sections that make up the composition.

ShortComposition is broken into sections
Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
276. Composition.section:motherInformation.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
278. Composition.section:motherInformation.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
280. Composition.section:motherInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
282. Composition.section:motherInformation.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
284. Composition.section:motherInformation.code
Definition

Mother's administrative information

ShortMother's administrative information
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92014-0&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
286. Composition.section:motherInformation.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
288. Composition.section:motherInformation.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control1..1
TypeReference(Patient - Mother - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
290. Composition.section:motherInformation.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
292. Composition.section:motherInformation.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
294. Composition.section:motherInformation.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
296. Composition.section:motherInformation.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ resolve()
298. Composition.section:motherInformation.entry:marriedDuringPregnancy
Slice NamemarriedDuringPregnancy
Definition

Was mother married at conception, at the time of birth, or at any time between conception and giving birth?

ShortMother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Mother Married During Pregnancy)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
300. Composition.section:motherInformation.entry:ssnRequestedForChild
Slice NamessnRequestedForChild
Definition

Was social security number requested for the child

ShortWas social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Social Security Number Requested For Child)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
302. Composition.section:motherInformation.entry:mothersEducation
Slice NamemothersEducation
Definition

Mother's education

ShortMother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Parent Education Level - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
304. Composition.section:motherInformation.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
306. Composition.section:motherInformation.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
308. Composition.section:fatherInformation
Slice NamefatherInformation
Definition

This section contains items from the father section on the Live Birth Certificate.

ShortFather section on the Live Birth Certificate
Control0..1
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
310. Composition.section:fatherInformation.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
312. Composition.section:fatherInformation.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
314. Composition.section:fatherInformation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
316. Composition.section:fatherInformation.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
318. Composition.section:fatherInformation.code
Definition

Father's administrative information

ShortFather's administrative information
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;92013-2&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
320. Composition.section:fatherInformation.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
322. Composition.section:fatherInformation.focus
Definition

The subject of the composition as a whole is the newborn baby. The focus of this section in the composition is the father.

ShortThe focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity.
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control1..1
TypeReference(RelatedPerson - Father Natural - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
324. Composition.section:fatherInformation.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
326. Composition.section:fatherInformation.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
328. Composition.section:fatherInformation.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
330. Composition.section:fatherInformation.entry
Definition

Entries that are contained in the fatherInformation section

ShortEntries that are contained in the fatherInformation section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • profile @ $this.resolve()
332. Composition.section:fatherInformation.entry:paternityAcknowledgementSigned
Slice NamepaternityAcknowledgementSigned
Definition

Whether or not a paternity acknowledgement was signed by the father if the mother was not married at conception, at the time of birth, or at any time between conception and giving birth.

ShortPaternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Paternity Acknowledgement Signed)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
334. Composition.section:fatherInformation.entry:fathersEducation
Slice NamefathersEducation
Definition

Father's education

ShortFather's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..1
This element is affected by the following invariants: cmp-2
TypeReference(Observation - Parent Education Level - Vital Records)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
336. Composition.section:fatherInformation.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
338. Composition.section:fatherInformation.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
340. Composition.section:patientsQuestionnaireResponse
Slice NamepatientsQuestionnaireResponse
Definition

The root of the sections that make up the composition.

ShortOptional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate
Control0..1
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
342. Composition.section:patientsQuestionnaireResponse.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
344. Composition.section:patientsQuestionnaireResponse.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
346. Composition.section:patientsQuestionnaireResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
348. Composition.section:patientsQuestionnaireResponse.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
350. Composition.section:patientsQuestionnaireResponse.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortQuestionnaire response Document
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control1..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;74465-6&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
352. Composition.section:patientsQuestionnaireResponse.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
354. Composition.section:patientsQuestionnaireResponse.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
356. Composition.section:patientsQuestionnaireResponse.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
358. Composition.section:patientsQuestionnaireResponse.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
360. Composition.section:patientsQuestionnaireResponse.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
362. Composition.section:patientsQuestionnaireResponse.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortQuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..1
This element is affected by the following invariants: cmp-2
TypeReference(QuestionnaireResponse)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
364. Composition.section:patientsQuestionnaireResponse.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
366. Composition.section:patientsQuestionnaireResponse.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))