Generated Narrative: StructureDefinition au-ps-composition Name Flags Card. Type Description & Constraints <a href="StructureDefinition-au-ps-composition-definitions.html#Composition" title="AU Patient Summary Composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.">Composition 0..* AUBaseComposition AU Patient Summary Composition This profile also complies with the profile Composition (IPS) #xD; meta #xD; profile SO 0..* canonical(StructureDefinition) Conformance claim to a specific Patient Summary specification Obligations Actor MAY:able-to-populate AU PS Producer #xD; text SO 0..1 Narrative Text summary of the resource, for human interpretation Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; identifier SO 0..1 Identifier Version-independent identifier for the Composition Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer #xD; status SO 1..1 code preliminary | final | amended | entered-in-error Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; type SO 1..1 CodeableConceptIPS Kind of composition ("Patient Summary") Required Pattern: At least the following Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 60591-5 #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.subject" title="Who or what the composition is about.#xD;#xA;In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).#xD;#xA;For the AU PS the subject is always the patient.">subject SO 1..1 Reference(AU PS Patient) Who and/or what the composition is about Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; reference SO 1..1 string Literal reference, Relative, internal or absolute URL Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer #xD; date SO 1..1 dateTime Composition editing time Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.author" title="Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.#xD;#xA;#xD;#xA;The type of author(s) contribute to determine the "nature"of the patient summary: e.g. a "human-curated" Vs. automatically generated ("software assembled"). The distinction between the two types of patient summary, "human-curated" or "software-assembled", is based on the authors recorded in the composition: the author will be a human (e.g. Practitioner), if the patient summary provenance type is "human-curated", or a device if the patient summary provenance type is "software-assembled". In the case of a "software-assembled" patient summary that is then verified by a human, the document provenance type will be "software-assembled" and the author will be the device or system that constructed the patient summary document, but an additional attester identity will name the human who performed this check.">author SO 1..* Reference(AU PS Practitioner | AU PS PractitionerRole | Device | AU PS Patient | AU PS RelatedPerson | AU PS Organization) Who and/or what authored the patient summary Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string The title of this patient summary Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; attester SO 0..* BackboneElement Attests to accuracy of composition Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; mode SO 1..1 code personal | professional | legal | official Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; time SO 0..1 dateTime When the composition was attested Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; party SO 0..1 Reference(AU PS Patient | AU PS RelatedPerson | AU PS Practitioner | AU PS PractitionerRole | AU PS Organization) Who attested the composition Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; custodian SO 0..1 Reference(AU PS Organization) Organization which maintains the composition Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; relatesTo 0..* BackboneElement Relationships to other compositions/documents #xD; target[x] 1..1 Target of the relationship #xD; targetIdentifier Identifier #xD; targetReference Reference(Composition | Composition (IPS) | AU PS Composition) #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.event" title="The main activity being described by a patient summary is the provision of healthcare over a period of time.#xD;#xA;In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. #xD;#xA;In the FHIR representation at least one event will be used to record this information.#xD;#xA;Additional data from outside this duration can also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the patient summary is generated by a GP, based on information recorded in his/her EHR-S, then the start value will represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.">Slices for event 0..* BackboneElement The clinical service(s) being documented Slice: Unordered, Open by value:code #xD; event:careProvisioningEvent SO 0..1 BackboneElement The care provisioning being documented Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Code(s) that apply to the event being documented Required Pattern: At least the following Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: PCPR #xD; period SO 0..1 Period The period covered by the documentation Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for section SO 3..* BackboneElement Sections composing the patient summary Slice: Unordered, Open by value:code Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; section:All Slices Content/Rules for all slices #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource) URL: http://hl7.org/fhir/StructureDefinition/note #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Obligations Actor SHALL:handle AU PS Consumer #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; section 0..0 Nested Section #xD; section:sectionProblems SOC 1..1 BackboneElement Patient Summary Problems Section Constraints: ips-comp-1 Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11450-4 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient Slice: Unordered, Open by profile:resolve() #xD; entry:problem SO 0..* Reference(AU PS Condition) A reference to data that supports this section Obligations Actor SHALL:able-to-populate AU PS Producer SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; emptyReason SO 0..1 CodeableConceptIPS Why the section is empty Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionAllergies" title="Slice sectionAllergies: Information about a patient's relevant allergies or intolerances, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, this section will list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this is to be clearly documented in this section.">section:sectionAllergies SOC 1..1 BackboneElement Patient Summary Allergies and Intolerances Section Constraints: ips-comp-1 Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 48765-2 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionAllergies.entry" title="The relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.#xD;#xA;At a minimum, will include currently active and any relevant historical allergies and adverse reactions.#xD;#xA; An entry can be used to document that no information about allergies is available, or that no allergies are known.">Slices for entry 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances (conditions) for that patient Slice: Unordered, Open by profile:resolve() #xD; entry:allergyOrIntolerance SO 0..* Reference(AU PS AllergyIntolerance) A reference to data that supports this section Obligations Actor SHALL:able-to-populate AU PS Producer SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; emptyReason SO 0..1 CodeableConceptIPS Why the section is empty Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionMedications" title="Slice sectionMedications: Information about a patient's medications relevant for the scope of the patient summary.#xD;#xA;The actual content could depend on the jurisdiction, it could report:#xD;#xA;#xD;#xA;- the currently active medications;#xD;#xA;#xD;#xA;- the current and past medications considered relevant by the authoring GP;#xD;#xA;#xD;#xA;- the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.#xD;#xA;#xD;#xA;In those cases medications are documented in the Patient Summary as medication statements or medication requests. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarising the subject's relevant medications.">section:sectionMedications SOC 1..1 BackboneElement Patient Summary Medication Summary Section Constraints: ips-comp-1 Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10160-0 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() #xD; entry:medicationStatementOrRequest SO 0..* Reference(AU PS MedicationStatement | AU PS MedicationRequest) A reference to data that supports this section Obligations Actor SHALL:able-to-populate AU PS Producer SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; emptyReason SO 0..1 CodeableConceptIPS Why the section is empty Obligations Actor SHALL:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionImmunizations" title="Slice sectionImmunizations: Information about a patient's current immunisation status and pertinent immunisation history.#xD;#xA;The primary use case for this section is to enable communication of a patient's immunisation status.#xD;#xA;It could contain the entire immunisation history that is relevant to the period of time being summarised.">section:sectionImmunizations SO 0..1 BackboneElement Patient Summary Immunizations Section Obligations Actor SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11369-6 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionImmunizations.entry" title="The patient's current immunisation status and pertinent immunisation history.#xD;#xA;The primary use case is to enable communication of a patient's immunisation status.#xD;#xA;It can contain the entire immunisation history relevant to the period of time being summarised. An entry can be used to document that no information about immunisations is available, or that no immunisations are known.">Slices for entry 0..* Reference(Immunization | DocumentReference) Patient's immunisation status and pertinent history Slice: Unordered, Open by profile:resolve() #xD; entry:immunization SO 0..* Reference(AU PS Immunization) A reference to data that supports this section Obligations Actor SHOULD:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionResults" title="Slice sectionResults: Information about a patient's relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.">section:sectionResults SO 0..1 BackboneElement Patient Summary Results Section Obligations Actor SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 30954-2 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionResults.entry" title="The relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.">Slices for entry 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient Slice: Unordered, Open by type:resolve(), profile:resolve() #xD; entry:results-observation-laboratory-pathology SO 0..* Reference(AU PS Pathology Result Observation) A reference to data that supports this section Obligations Actor SHOULD:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; entry:results-observation-radiology SO 0..* Reference(Observation Results - Radiology (IPS)) A reference to data that supports this section Obligations Actor SHOULD:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; entry:results-diagnosticReport SO 0..* Reference(DiagnosticReport (IPS)) A reference to data that supports this section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionProceduresHx" title="Slice sectionProceduresHx: Information about a patient's past procedures that are pertinent to the scope of this patient summary.#xD;#xA;Procedures could refer, for example to:#xD;#xA;1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;2. Therapeutic procedure: e.g. dialysis;#xD;#xA;3. Surgical procedure: e.g. appendectomy">section:sectionProceduresHx SO 0..1 BackboneElement Patient Summary History of Procedures Section Obligations Actor SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47519-4 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionProceduresHx.entry" title="The patient's past procedures that are pertinent to the scope of this patient summary.#xD;#xA;Procedures can refer for example to:#xD;#xA;1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;2. Therapeutic procedure: e.g. dialysis;#xD;#xA;3. Surgical procedure: e.g. appendectomy. An entry can be used to document that no information about past procedures is available, or that no relevant past procedures are known.">Slices for entry 0..* Reference(Procedure | DocumentReference) Patient past procedures pertinent to the scope of this patient summary Slice: Unordered, Open by profile:resolve() #xD; entry:procedure SO 0..* Reference(AU PS Procedure) A reference to data that supports this section Obligations Actor SHOULD:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; section:sectionMedicalDevices SO 0..1 BackboneElement Patient Summary Medical Devices Section Obligations Actor SHOULD:populate-if-known AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 46264-8 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(DeviceUseStatement | DocumentReference) Patient history of medical device use Slice: Unordered, Open by profile:resolve() #xD; entry:deviceStatement SO 0..* Reference(DeviceUseStatement (IPS)) A reference to data that supports this section Obligations Actor SHOULD:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; section:sectionAdvanceDirectives SO 0..1 BackboneElement Patient Summary Advance Directives Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 42348-3 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Consent | DocumentReference) A patient's advance directives Slice: Unordered, Open by profile:resolve() #xD; entry:advanceDirectivesConsent 0..* Reference(Consent) A reference to data that supports this section #xD; section:sectionAlerts SO 0..1 BackboneElement Patient Summary Alerts Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 104605-1 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Flag | DocumentReference) Alert information Slice: Unordered, Open by profile:resolve() #xD; entry:alertsFlag 0..* Reference(Flag - Alert (IPS)) A reference to data that supports this section #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionFunctionalStatus" title="Slice sectionFunctionalStatus: Information about a patient's functional status including a description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status can in fact influence decisions about how to administer treatments.">section:sectionFunctionalStatus SO 0..1 BackboneElement Patient Summary Functional Status Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 47420-5 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Condition | ClinicalImpression | DocumentReference) Disabilities and functional assessments Slice: Unordered, Open by profile:resolve() #xD; entry:disability 0..* Reference(AU PS Condition) A reference to data that supports this section #xD; entry:functionalAssessment 0..* Reference(ClinicalImpression) A reference to data that supports this section #xD; section:sectionPastProblems SO 0..1 BackboneElement Patient Summary History of Past Illness Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 11348-0 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Condition | DocumentReference) Conditions the patient suffered in the past Slice: Unordered, Open by profile:resolve() #xD; entry:pastProblem 0..* Reference(AU PS Condition) A reference to data that supports this section #xD; section:sectionPregnancyHx SO 0..1 BackboneElement Patient Summary History of Pregnancy Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 10162-6 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Observation | DocumentReference) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies Slice: Unordered, Open by profile:resolve() #xD; entry:pregnancyStatus 0..* Reference(Observation Pregnancy - Status (IPS)) A reference to data that supports this section #xD; entry:pregnancyOutcome 0..* Reference(Observation Pregnancy - Outcome (IPS)) A reference to data that supports this section #xD; section:sectionPatientStory SO 0..1 BackboneElement Patient Summary Patient Story Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 81338-6 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; entry 0..* Reference(Resource) Patient Story resources #xD; section:sectionPlanOfCare SO 0..1 BackboneElement Patient Summary Plan of Care Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 18776-5 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(CarePlan | ImmunizationRecommendation | DocumentReference) Structured care plans Slice: Unordered, Open by profile:resolve() #xD; entry:carePlan 0..* Reference(CarePlan) A reference to data that supports this section #xD; entry:immunizationRecommendation 0..* Reference(ImmunizationRecommendation) A reference to data that supports this section #xD; section:sectionSocialHistory SO 0..1 BackboneElement Patient Summary Social History Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 29762-2 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; Slices for entry 0..* Reference(Observation | DocumentReference) Health related "lifestyle factors" or "lifestyle observations" Slice: Unordered, Open by profile:resolve() #xD; entry:smokingTobaccoUse 0..1 Reference(AU PS Smoking Status) A reference to data that supports this section #xD; entry:alcoholUse 0..1 Reference(Observation Social History - Alcohol Use (IPS)) A reference to data that supports this section #xD; <a href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionVitalSigns" title="Slice sectionVitalSigns: Information about a patient's vital signs including blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included.">section:sectionVitalSigns SO 0..1 BackboneElement Patient Summary Vital Signs Section Obligations Actor SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; title SO 1..1 string Label for section (e.g. for ToC) Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; code SO 1..1 CodeableConceptIPS Classification of section (recommended) Required Pattern: At least the following Obligations Actor SHALL:handle AU PS Consumer #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: 8716-3 #xD; text SO 1..1 Narrative Text summary of the section, for human interpretation Obligations Actor SHALL:populate AU PS Producer SHALL:handle AU PS Consumer SHOULD:display AU PS Consumer #xD; <a style="font-style: italic; font-style: italic" href="StructureDefinition-au-ps-composition-definitions.html#Composition.section:sectionVitalSigns.entry" title="The notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included">Slices for entry 0..* Reference(Observation | DocumentReference) Notable vital signs or physical findings Slice: Unordered, Open by profile:resolve() #xD; entry:vitalSign 0..* Reference(Vital Signs Profile) A reference to data that supports this section #xD; Documentation for this format
This profile sets minimum expectations for a Composition resource in the context of a patient summary in an Australian context. It is based on [AU Base Composition](http://hl7.org.au/fhir/StructureDefinition/au-composition) and imposes [Composition (IPS)](http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips). AU Patient Summary (AU PS) is specified in this guide as a HL7 FHIR document (a Bundle including a Composition), composed by a set of potentially reusable 'minimal' data blocks (the AU PS profiles).
Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved.
AU Patient Summary Composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.
While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Conformance claim to a specific Patient Summary specification
The conformance of this Composition to a specific version of a Patient Summary specification (e.g. AU PS 1.0.0 conformance claim http://hl7.org.au/fhir/ps/StructureDefinition/au-ps-composition|1.0.0, IPS 2.0.0 conformance claim http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips|2.0.0)
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Who and/or what should receive a copy of the composition
A recipient who should receive a copy of the composition. A recipient is an entity to whom a copy of the composition is directed at the time of authoring of the composition.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Version-independent identifier for the Composition
A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
preliminary | final | amended | entered-in-error
The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
Need to be able to mark interim, amended, or withdrawn compositions or documents.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
The workflow/clinical status of the composition.
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
Specifies that this composition refers to a Patient Summary (Loinc "60591-5")
For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.
Key metadata element describing the composition, used in searching/filtering.
A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.
This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).
Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
Who and/or what the composition is about
Who or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the AU PS the subject is always the patient.
For clinical documents, this is usually the patient.
Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Describes the clinical encounter or type of care this documentation is associated with.
Provides context for the composition and supports searching.
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
The composition editing time, when the composition was last logically changed by the author.
The Last Modified Date on the composition may be after the date of the document was attested without being changed.
dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](http://hl7.org/fhir/R4/bundle-definitions.html#Bundle.timestamp) is the date of packaging.
DocumentReference.content.attachment.date, DocumentReference.created
Who and/or what authored the patient summary
Identifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the patient summary: e.g. a "human-curated" Vs. automatically generated ("software assembled"). The distinction between the two types of patient summary, "human-curated" or "software-assembled", is based on the authors recorded in the composition: the author will be a human (e.g. Practitioner), if the patient summary provenance type is "human-curated", or a device if the patient summary provenance type is "software-assembled". In the case of a "software-assembled" patient summary that is then verified by a human, the document provenance type will be "software-assembled" and the author will be the device or system that constructed the patient summary document, but an additional attester identity will name the human who performed this check.
Identifies who is responsible for the content.
Official human-readable label for the composition. For this document the title would likely include the text "Patient Summary" or any equivalent translation and other relevant document information.This can include information like the patient name and time generated.
For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
DocumentReference.description, DocumentReference.content.attachment.title
The code specifying the level of confidentiality of the Composition.
The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.
Codes specifying the level of confidentiality of the composition.
A participant who has attested to the accuracy of the composition/document.
Identifies responsibility for the accuracy of the composition content.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
personal | professional | legal | official
The type of attestation the authenticator offers.
Indicates the level of authority of the attestation.
The way in which a person authenticated a composition.
implied by .authenticator/.legalAuthenticator
When the composition was attested by the party.
Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
./time[type="TS" and isNormalDatatype()]
Who attested the composition in the specified way.
Identifies who has taken on the responsibility for accuracy of the composition content.
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
Organization which maintains the composition
Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Identifies where to go to find the current version, where to report issues, etc.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Relationships to other compositions/documents
Relationships that this composition has with other compositions or documents that already exist.
A document is a version specific composition.
The type of relationship that this composition has with anther composition or document.
If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
The type of relationship between documents.
The target composition/document of this relationship.
.target[classCode="DOC", moodCode="EVN"].id
The clinical service(s) being documented
The main activity being described by a patient summary is the provision of healthcare over a period of time. In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event will be used to record this information. Additional data from outside this duration can also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the patient summary is generated by a GP, based on information recorded in his/her EHR-S, then the start value will represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.
The event needs to be consistent with the type element, though can provide further information if desired.
Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Code(s) that apply to the event being documented
This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
This list of codes represents the main clinical acts being documented.
The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
The provision of healthcare over a period of time this patient summary is documenting.
The root of the sections that make up the patient summary composition.
A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
exists(f:text) or exists(f:entry) or exists(f:section)
A section can only have an emptyReason if it is empty
not(exists(f:emptyReason) and exists(f:entry))
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
Additional notes that apply to the section (but not to specific resource)
This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element
The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
A code identifying the kind of content contained within the section. This must be consistent with the section title.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Provides computable standardized labels to topics within the document.
Classification of a section of a composition/document.
Identifies who is responsible for the information in this section, not necessarily who typed it in.
Who/what the section is about, when it is not about the subject of composition
The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
.subject? (CDA did not differentiate between subject and focus)
Text summary of the section, for human interpretation
A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
The processing mode that applies to this section.
Specifies the order applied to the items in the section entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
What order applies to the items in the entry.
.outboundRelationship[typeCode=COMP].sequenceNumber > 1
A reference to data that supports this section
A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
Information about a patient's clinical problems or conditions that are currently being monitored.
Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())
(/f:entry.reference and not /f:emptyReason) or (not(/f:emptyReason) and /f:entry.reference)
Clinical problems or conditions currently being monitored for the patient
The clinical problems or conditions currently being monitored for the patient. An entry can be used to document that no information about problems is available, or that no relevant problems are known.
Patient Summary Allergies and Intolerances Section
Information about a patient's relevant allergies or intolerances, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, this section will list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this is to be clearly documented in this section.
Relevant allergies or intolerances (conditions) for that patient
The relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, will include currently active and any relevant historical allergies and adverse reactions. An entry can be used to document that no information about allergies is available, or that no allergies are known.
Patient Summary Medication Summary Section
Information about a patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report: - the currently active medications; - the current and past medications considered relevant by the authoring GP; - the patient prescriptions or dispensations automatically extracted by a regional or a national EHR. In those cases medications are documented in the Patient Summary as medication statements or medication requests. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarising the subject's relevant medications.
Medications relevant for the scope of the patient summary
The medications relevant for the scope of the patient summary, or an indication that the subject is known not to be on any relevant medication; either that no information is available about medications.
Information about a patient's current immunisation status and pertinent immunisation history. The primary use case for this section is to enable communication of a patient's immunisation status. It could contain the entire immunisation history that is relevant to the period of time being summarised.
Patient's immunisation status and pertinent history
The patient's current immunisation status and pertinent immunisation history. The primary use case is to enable communication of a patient's immunisation status. It can contain the entire immunisation history relevant to the period of time being summarised. An entry can be used to document that no information about immunisations is available, or that no immunisations are known.
Information about a patient's relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.
Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient
The relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.
Patient Summary History of Procedures Section
Information about a patient's past procedures that are pertinent to the scope of this patient summary. Procedures could refer, for example to: 1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy
Patient past procedures pertinent to the scope of this patient summary
The patient's past procedures that are pertinent to the scope of this patient summary. Procedures can refer for example to: 1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy. An entry can be used to document that no information about past procedures is available, or that no relevant past procedures are known.
Information about a patient's history of medical device use.
The patient's history of medical device use. An entry can be used to document that no information about medical device use is available, or that no relevant medical device use is known.
Patient Summary Advance Directives Section
Information about a patient's advance directives.
Information about the patient's advance directive.
Information about a patient's alerts pertinent to the scope of the patient summary including flagging potential concerns and/or dangers to/from the patient and can also include obstacles to care.
The alert information to be communicated; can optionally reference other resources in the patient summary.
Patient Summary Functional Status Section
Information about a patient's functional status including a description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status can in fact influence decisions about how to administer treatments.
The patient's capability to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status can in fact influence decisions about how to administer treatments.
Patient Summary History of Past Illness Section
Information about a patient's conditions that were suffered in the past and are no longer tracked in the Problem List.
Conditions the patient suffered in the past
The conditions the patient suffered in the past and are no longer tracked in the Problem List.
Patient Summary History of Pregnancy Section
Information about whether a patient is currently pregnant or not and can contain additional summarising information about the outcome of earlier pregnancies.
Current pregnancy status and, optionally, information about the outcome of earlier pregnancies
Information about whether the patient is currently pregnant or not. It can contain additional summarising information about the outcome of earlier pregnancies.
Information about what matters to a patient. This can include needs, strengths, values, concerns and preferences to others providing support and care. The patient's story, provided here, can be told by the patient or by a proxy.
The information about what matters to a patient. This can include needs, strengths, values, concerns and preferences to others providing support and care.
Information about a patient's plans of care containing the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
The dynamic, personalised care plans including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process.
Information about a patient's health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits, alcohol consumption, diets, risky habits).
Health related "lifestyle factors" or "lifestyle observations"
The patient's health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits, alcohol consumption, diets, risky habits.)
Information about a patient's vital signs including blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included.
Notable vital signs or physical findings
The notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included