Cross Border Data Exchange IG
1.0.0 - CI Build
Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions
Official URL: http://interopehrate.eu/fhir/StructureDefinition/Composition-HospitalDischargeReport-IEHR | Version: 1.0.0 | |||
Draft as of 2024-04-08 | Computable Name: HospitalDischargeReportIEHR |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CompositionIEHR
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:sectionHospitalAdmissionDx | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredAdmissionDx | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | |
entry:unstructuredAdmissionDx | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalAdmissionHistoryAndPhysicalNote | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |
entry | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHistoryGeneral | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
section:sectionPhysicalExamination | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredPhysicalExamination | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | |
entry:unstructuredPhysicalExamination | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionMedicationsOnAdmission | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredMedicationsOnAdmission | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
entry:unstructuredMedicationsOnAdmission | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalCourse | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | |
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalDischargeStudiesSummary | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |
section:sectionSelectedMedicineAdministeredDuringHospitalization | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredMedication | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
entry:unstructuredMedication | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalDischargeDx | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredHospitalDischargeDx | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | |
entry:unstructuredHospitalDischargeDx | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionDischargeMedications | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredDischargeMedication | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section | |
entry:unstructuredDischargeMedication | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionTreatmentPlan | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredTreatmentPlan | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section | |
entry:unstructuredTreatmentPlan | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionAllergies | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredAllergies | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | |
entry:unstructuredAllergies | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
Provenance | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Human Readable name/title |
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
section:sectionHospitalAdmissionDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredAdmissionDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section |
entry:unstructuredAdmissionDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalAdmissionHistoryAndPhysicalNote | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |
entry | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHistoryGeneral | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
section:sectionPhysicalExamination | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredPhysicalExamination | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section |
entry:unstructuredPhysicalExamination | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionMedicationsOnAdmission | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredMedicationsOnAdmission | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
entry:unstructuredMedicationsOnAdmission | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalCourse | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section |
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalDischargeStudiesSummary | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |
section:sectionSelectedMedicineAdministeredDuringHospitalization | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredMedication | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
entry:unstructuredMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalDischargeDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredHospitalDischargeDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section |
entry:unstructuredHospitalDischargeDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionDischargeMedications | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredDischargeMedication | C | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section |
entry:unstructuredDischargeMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionTreatmentPlan | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredTreatmentPlan | C | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section |
entry:unstructuredTreatmentPlan | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionAllergies | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredAllergies | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
entry:unstructuredAllergies | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC code 81218-0http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.section:sectionHospitalAdmissionDx.code | example | Pattern: LOINC code 46241-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.code | example | Pattern: LOINC code 47039-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHistoryGeneral.code | example | Pattern: LOINC code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPhysicalExamination.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicationsOnAdmission.code | example | Pattern: LOINC code 42346-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.code | example | Pattern: LOINC code 8648-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalDischargeStudiesSummary.code | example | Pattern: LOINC code 11493-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.code | example | Pattern: LOINC code 8677-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalDischargeDx.code | example | Pattern: LOINC code 11535-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDischargeMedications.code | example | Pattern: LOINC code 10183-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatmentPlan.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
Provenance | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 0..1 | Reference(Patient-IEHR | Practitioner (IPS) | Group | Device | Location) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter-IEHR) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | Composition editing time | ||||
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Human Readable name/title | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | C | 0..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalAdmissionDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredAdmissionDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredAdmissionDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalAdmissionHistoryAndPhysicalNote | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHistoryGeneral | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPhysicalExamination | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredPhysicalExamination | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredPhysicalExamination | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionMedicationsOnAdmission | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredMedicationsOnAdmission | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredMedicationsOnAdmission | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalCourse | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalDischargeStudiesSummary | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionSelectedMedicineAdministeredDuringHospitalization | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredMedication | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalDischargeDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredHospitalDischargeDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredHospitalDischargeDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionDischargeMedications | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredDischargeMedication | C | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredDischargeMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionTreatmentPlan | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredTreatmentPlan | C | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredTreatmentPlan | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAllergies | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredAllergies | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredAllergies | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | Pattern: LOINC code 81218-0http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.code | example | Pattern: LOINC code 46241-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.code | example | Pattern: LOINC code 47039-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.code | example | Pattern: LOINC code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.code | example | Pattern: LOINC code 42346-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.code | example | Pattern: LOINC code 8648-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.code | example | Pattern: LOINC code 11493-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.code | example | Pattern: LOINC code 8677-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.code | example | Pattern: LOINC code 11535-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.code | example | Pattern: LOINC code 10183-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
per-1 | error | Composition.event.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
This structure is derived from CompositionIEHR
Summary
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CompositionIEHR
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:sectionHospitalAdmissionDx | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredAdmissionDx | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | |
entry:unstructuredAdmissionDx | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalAdmissionHistoryAndPhysicalNote | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |
entry | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHistoryGeneral | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
section:sectionPhysicalExamination | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredPhysicalExamination | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | |
entry:unstructuredPhysicalExamination | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionMedicationsOnAdmission | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredMedicationsOnAdmission | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
entry:unstructuredMedicationsOnAdmission | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalCourse | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | |
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalDischargeStudiesSummary | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |
section:sectionSelectedMedicineAdministeredDuringHospitalization | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredMedication | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
entry:unstructuredMedication | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionHospitalDischargeDx | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredHospitalDischargeDx | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | |
entry:unstructuredHospitalDischargeDx | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionDischargeMedications | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredDischargeMedication | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section | |
entry:unstructuredDischargeMedication | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionTreatmentPlan | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredTreatmentPlan | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section | |
entry:unstructuredTreatmentPlan | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
section:sectionAllergies | 0..* | BackboneElement | Composition is broken into sections | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | |
entry:structuredAllergies | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | |
entry:unstructuredAllergies | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
Provenance | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Human Readable name/title |
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
section:sectionHospitalAdmissionDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredAdmissionDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section |
entry:unstructuredAdmissionDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalAdmissionHistoryAndPhysicalNote | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |
entry | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHistoryGeneral | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
section:sectionPhysicalExamination | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredPhysicalExamination | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section |
entry:unstructuredPhysicalExamination | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionMedicationsOnAdmission | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredMedicationsOnAdmission | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
entry:unstructuredMedicationsOnAdmission | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalCourse | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section |
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalDischargeStudiesSummary | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |
section:sectionSelectedMedicineAdministeredDuringHospitalization | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredMedication | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
entry:unstructuredMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionHospitalDischargeDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredHospitalDischargeDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section |
entry:unstructuredHospitalDischargeDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionDischargeMedications | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredDischargeMedication | C | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section |
entry:unstructuredDischargeMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionTreatmentPlan | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredTreatmentPlan | C | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section |
entry:unstructuredTreatmentPlan | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
section:sectionAllergies | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
entry:structuredAllergies | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
entry:unstructuredAllergies | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC code 81218-0http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.section:sectionHospitalAdmissionDx.code | example | Pattern: LOINC code 46241-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.code | example | Pattern: LOINC code 47039-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHistoryGeneral.code | example | Pattern: LOINC code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPhysicalExamination.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedicationsOnAdmission.code | example | Pattern: LOINC code 42346-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.code | example | Pattern: LOINC code 8648-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalDischargeStudiesSummary.code | example | Pattern: LOINC code 11493-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.code | example | Pattern: LOINC code 8677-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalDischargeDx.code | example | Pattern: LOINC code 11535-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionDischargeMedications.code | example | Pattern: LOINC code 10183-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionTreatmentPlan.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | CompositionIEHR | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
Provenance | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81218-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 0..1 | Reference(Patient-IEHR | Practitioner (IPS) | Group | Device | Location) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter-IEHR) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | Composition editing time | ||||
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Human Readable name/title | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | C | 0..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalAdmissionDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46241-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredAdmissionDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredAdmissionDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalAdmissionHistoryAndPhysicalNote | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47039-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHistoryGeneral | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPhysicalExamination | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredPhysicalExamination | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredPhysicalExamination | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionMedicationsOnAdmission | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42346-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredMedicationsOnAdmission | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredMedicationsOnAdmission | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalCourse | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(BioSignal-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredRelevantDiagnosticTestsAndOrLaboratoryData | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalDischargeStudiesSummary | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11493-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionSelectedMedicineAdministeredDuringHospitalization | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8677-7 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredMedication | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionHospitalDischargeDx | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredHospitalDischargeDx | C | 0..* | Reference(LaboratoryReport-IEHR | ImagingReport-IEHR | BioSignalReport-IEHR | Condition (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredHospitalDischargeDx | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionDischargeMedications | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10183-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredDischargeMedication | C | 0..* | Reference(Medication Statement (IPS) | MedicationRequestPrescription-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredDischargeMedication | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionTreatmentPlan | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredTreatmentPlan | C | 0..* | Reference(TreatmentPlan-IEHR) | A reference to data that supports this section | ||||
entry:unstructuredTreatmentPlan | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAllergies | C | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
ConfidentialityCode | 0..1 | CodeableConcept | SectionConfidentiality URL: http://interopehrate.eu/fhir/StructureDefinition/ConfidentialityExtension-IEHR Binding: V3 Value SetConfidentialityClassification (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:structuredAllergies | C | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | ||||
entry:unstructuredAllergies | C | 0..* | Reference(DocumentReference-IEHR) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | Pattern: LOINC code 81218-0http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.code | example | Pattern: LOINC code 46241-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionDx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.code | example | Pattern: LOINC code 47039-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.code | example | Pattern: LOINC code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHistoryGeneral.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.code | example | Pattern: LOINC code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPhysicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.code | example | Pattern: LOINC code 42346-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionMedicationsOnAdmission.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.code | example | Pattern: LOINC code 8648-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.code | example | Pattern: LOINC code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.code | example | Pattern: LOINC code 11493-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeStudiesSummary.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.code | example | Pattern: LOINC code 8677-7http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.code | example | Pattern: LOINC code 11535-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalDischargeDx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.code | example | Pattern: LOINC code 10183-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionDischargeMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.code | example | Pattern: LOINC code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionTreatmentPlan.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Pattern: LOINC code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:sectionHospitalAdmissionDx, Composition.section:sectionHospitalAdmissionHistoryAndPhysicalNote, Composition.section:sectionHistoryGeneral, Composition.section:sectionPhysicalExamination, Composition.section:sectionMedicationsOnAdmission, Composition.section:sectionHospitalCourse, Composition.section:sectionRelevantDiagnosticTestsAndOrLaboratoryData, Composition.section:sectionHospitalDischargeStudiesSummary, Composition.section:sectionSelectedMedicineAdministeredDuringHospitalization, Composition.section:sectionHospitalDischargeDx, Composition.section:sectionDischargeMedications, Composition.section:sectionTreatmentPlan, Composition.section:sectionAllergies | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | 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 | error | Composition | 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 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
per-1 | error | Composition.event.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
This structure is derived from CompositionIEHR
Summary
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron