Generated Narrative: StructureDefinition composition-eu-eps Name Flags Card. Type Description & Constraints <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition" title="Patient Summary composition. #xD;#xA;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. #xD;#xA;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..* Composition Patient Summary composition This profile also imposes the profile Composition (IPS) (2.0.0) #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:version 0..1 string Business version URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version #xD; identifier 0..1 Identifier PS business identifier #xD; status 1..1 code PS status #xD; type 1..1 CodeableConceptIPS(2.0.0) Kind of composition ("Patient Summary") #xD; <a href="StructureDefinition-composition-eu-eps-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 PS the subject is always the patient.">subject 1..1 Reference(Patient (EPS)) Who and/or what the composition is about #xD; date 1..1 dateTime PS date #xD; author 1..* Reference(Practitioner (EU core)(2.0.0-ballot) | PractitionerRole (EU core)(2.0.0-ballot) | Device | Organization (EU core)(2.0.0-ballot) | Patient (EU core)(2.0.0-ballot) | RelatedPerson) Who and/or what authored the Patient Summary #xD; title 1..1 string Patient Summary #xD; attester #xD; mode 1..1 code The type of attestation #xD; party 0..1 Reference(Practitioner (EU core)(2.0.0-ballot) | PractitionerRole (EU core)(2.0.0-ballot) | Organization (EU core)(2.0.0-ballot) | Patient (EPS) | RelatedPerson) Who attested the composition #xD; custodian 0..1 Reference(Organization (EU core)(2.0.0-ballot)) Custodian of the Patient Summary #xD; Slices for section 3..* BackboneElement Sections composing the IPS Slice: Unordered, Open by value:code #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 1..1 string Label for section (e.g. for ToC) #xD; code 1..1 CodeableConcept Classification of section (recommended) #xD; text 1..1 Narrative Text summary of the section, for human interpretation #xD; section 0..0 Nested Section #xD; section:sectionProblems C 1..1 BackboneElement EPS Problems Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by type:resolve() #xD; entry:problem 0..1 Reference(Condition (EU core)) A reference to data that supports this section #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionAllergies" title="Slice sectionAllergies: This section documents the relevant allergies or intolerances for that patient, describing the kind of reaction - e.g. rash, anaphylaxis,.. - preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should 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 should be clearly documented in the section.">section:sectionAllergies C 1..1 BackboneElement EPS Allergies and Intolerances Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(AllergyIntolerance | DocumentReference) allergyOrIntolerance Slice: Unordered, Open by type:resolve() #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionAllergies.entry:allergyOrIntolerance" title="Slice allergyOrIntolerance: It lists the relevant allergies or intolerances for that patient, describing the kind of reaction - e.g. rash, anaphylaxis,.. - preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should 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 should be clearly documented in the section.">entry:allergyOrIntolerance 0..1 Reference(Allergy Intolerance (EU core)) Relevant allergies or intolerances for that patient. #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionMedications" title="Slice sectionMedications: The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:#xA; * the currently active medications;#xA; * the current and past medications considered relevant by the authoring GP;#xA; * the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.#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 summarizing the subject's relevant medications.">section:sectionMedications C 1..1 BackboneElement EPS Medication Summary Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(MedicationStatement (EU core) | MedicationRequest (EPS) | MedicationAdministration (EPS) | MedicationDispense (EPS)) medicationStatementOrRequest Slice: Unordered, Open by type:resolve() #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionMedications.entry:medicationStatementOrRequest" title="Slice medicationStatementOrRequest: This list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication; either that no information is available about medications.">entry:medicationStatementOrRequest 0..1 Reference(MedicationStatement (EU core)) Medications relevant for the scope of the patient summary #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionImmunizations" title="Slice sectionImmunizations: The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.">section:sectionImmunizations C 0..1 BackboneElement EPS Immunizations Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; <a style="font-style: italic; font-style: italic" href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionImmunizations.entry" title="It defines the patient's current immunization status and pertinent immunization history.#xD;#xA;The primary use case for the Immunization Section is to enable communication of a patient's immunization status.#xD;#xA;It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.">Slices for entry 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() #xD; entry:immunization 0..1 Reference(Immunization (EU core)) A reference to data that supports this section #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionResults" title="Slice sectionResults: his section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.">section:sectionResults C 0..1 BackboneElement EPS Results Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Observation | DiagnosticReport | DocumentReference) EPS Results entry Slice: Unordered, Open by type:resolve() #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionResults.entry:results-observation-laboratory-pathology" title="Slice results-observation-laboratory-pathology: Laboratory or pathology in vitro diagnostic test or panel/study. In case of a panel or multiple-observation study, the results of the panel or study appear as sub-observations. In this case this top-level Observation acts as a grouper of all the observations belonging to the panel or study.">entry:results-observation-laboratory-pathology 0..1 Reference(Observation Results - Laboratory/Pathology (IPS)) Laboratory and pathology results #xD; entry:results-observation-radiology 0..1 Reference(Observation Results - Radiology (IPS)(2.0.0)) Radiology results #xD; entry:results-diagnosticReport 0..1 Reference(DiagnosticReport (EU core)) EPS DiagnosticReport #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionProceduresHx" title="Slice sectionProceduresHx: The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:#xD;#xA;#xA; 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;#xA; 2. Therapeutic procedure: e.g. dialysis;#xD;#xA;#xA; 3. Surgical procedure: e.g. appendectomy#xD;#xA;">section:sectionProceduresHx C 0..1 BackboneElement EPS History of Procedures Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Procedure | DocumentReference) Slice on procedure Slice: Unordered, Open by type:resolve() #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionProceduresHx.entry:procedure" title="Slice procedure: It lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:#xD;#xA;#xA; 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)#xD;#xA;#xA; 2. Therapeutic procedure: e.g. dialysis;#xD;#xA;#xA; 3. Surgical procedure: e.g. appendectomy#xD;#xA;">entry:procedure 0..1 Reference(Procedure (EU core)) Patient past procedures pertinent to the scope of this document. #xD; section:sectionMedicalDevices C 0..1 BackboneElement EPS Medical Devices Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(DeviceUseStatement | DocumentReference) EPS Medical Device entry Slice: Unordered, Open by type:resolve() #xD; entry:deviceStatement 0..1 Reference(DeviceUseStatement (EPS)) Patient history of medical device use #xD; section:sectionAdvanceDirectives C 0..1 BackboneElement Advance Directives Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; entry 0..* Reference(Consent (Advance Directives EPS) | DocumentReference) A reference to data that supports this section #xD; section:sectionAlert C 0..1 BackboneElement EPS Alerts Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Flag | DocumentReference) EPS Alerts entry Slice: Unordered, Open by type:resolve() #xD; entry:flag 0..1 Reference(Flag (EU core)) Alert information #xD; section:sectionFunctionalStatus C 0..1 BackboneElement Functional Status Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Resource) Functional Status short Slice: Unordered, Open by type:resolve() #xD; entry:functionalStatus 0..1 Reference(Condition (EU core)) SHORT functionalStatus #xD; section:sectionPastProblems 0..1 BackboneElement Composition is broken into sections #xD; section:sectionPregnancyHx C 0..1 BackboneElement Pregnancy History Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Resource) Pregnancy History short Slice: Unordered, Open by type:resolve() #xD; entry:pregnancyStatus 0..1 Reference(Observation Pregnancy - Status (IPS)(2.0.0)) Pregnancy status #xD; entry:pregnancyOutcome 0..1 Reference(Observation Pregnancy - Outcome (IPS)(2.0.0)) Pregnancy outcome #xD; section:sectionPatientStory 0..1 BackboneElement Composition is broken into sections #xD; <a href="StructureDefinition-composition-eu-eps-definitions.html#Composition.section:sectionPlanOfCare" title="Slice sectionPlanOfCare: The health maintenance care plan section contains a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient\’s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes.">section:sectionPlanOfCare 0..1 BackboneElement Health Maintenance Care Plan #xD; section:sectionSocialHistory 0..1 BackboneElement Social History #xD; section:sectionVitalSigns C 0..1 BackboneElement Vital Signs Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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; Slices for entry 0..* Reference(Resource) Vital Signs short Slice: Unordered, Open by type:resolve() #xD; entry:vitalSign 0..1 Reference(Vital Signs Profile) SHORT vitalSign #xD; section:sectionTravelHx C 0..1 BackboneElement Travel History Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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: 10182-4 #xD; entry 0..* Reference(Observation: country visited (HDR)) A reference to data that supports this section #xD; section:sectionPatientHx C 0..1 BackboneElement Patient History Section Constraints: ips-comp-1 #xD; Slices for extension Content/Rules for all slices #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; code 1..1 CodeableConceptIPS(2.0.0) Classification of section (recommended) Required Pattern: At least the following #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: 11329-0 #xD; Documentation for this format
Clinical document used to represent a Patient Summary for the scope of this project.
Used by permission of HL7 Europe, all rights reserved Creative Commons License
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())
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
This cross-version extension represents Composition.version from http://hl7.org/fhir/StructureDefinition/Composition|5.0.0 for use in FHIR R4.
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).
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.
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
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.
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 refer to a Patient Summary
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 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.
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.
Identifies who is responsible for the content.
Official human-readable label for the composition. For this document should be "Patient Summary" or any equivalent translation
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.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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.
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
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()]
Identifies the organization that is responsible for ongoing maintenance of the Patient Summary, and ensures that it remains available for access by other parties.
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 clinical service, such as a colonoscopy or an appendectomy, being documented.
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 root of the sections that make up the IPS 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.
The EPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
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.
It lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known.
This section documents the relevant allergies or intolerances for that patient, describing the kind of reaction - e.g. rash, anaphylaxis,.. - preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should 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 should be clearly documented in the section.
Relevant allergies or intolerances for that patient.
It lists the relevant allergies or intolerances for that patient, describing the kind of reaction - e.g. rash, anaphylaxis,.. - preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should 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 should be clearly documented in the section.
The medication summary section contains a description of the 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 summarizing the subject's relevant medications.
Medications relevant for the scope of the patient summary
This list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication; either that no information is available about medications.
The Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
Patient's immunization status and pertinent history.
It defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.
his section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
Laboratory or pathology in vitro diagnostic test or panel/study. In case of a panel or multiple-observation study, the results of the panel or study appear as sub-observations. In this case this top-level Observation acts as a grouper of all the observations belonging to the panel or study.
This observation may represent the conclusions of a diagnostic procedure such a Chest RX, or it may group the set of results produced by that single or multi-modality procedure.
DiagnosticReport resource to represent diagnostic test and procedure reports in a patient summary
The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may 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 document.
It lists the patient past procedures that are pertinent to the scope of this document. Procedures may 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
The medical devices section contains narrative text and coded entries describing the patient history of medical device use.
It describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known.
The advance directives section contains a narrative description of patient's advance directive.
The alerts section flags potential concerns and/or dangers to/from the patient and may also include obstacles to care.
Contains alert information to be communicated. May optionally reference other resources in IPS.lags
The functional status section contains a narrative description of the patient's functional status. It includes entries for functional status as described in related profiles
The root of the sections that make up the composition.
The pregnancy history section contains a narrative description of the patient's pregnancy history. It includes entries for pregnancy history as described in related profiles
The health maintenance care plan section contains a description of the expectations for wellness care including proposals, goals, and order requests for monitoring, tracking, or improving the lifetime condition of the patient with goals of educating the patient on how to reduce the modifiable risks of the patient\’s genetic, behavioral, and environmental pre-conditions and otherwise optimizing lifetime outcomes.
The social history section contains a narrative description of the person\’s beliefs, home life, community life, work life, hobbies, and risky habits. It includes Social History Observations.
The vital signs section contains a narrative description of the patient's vital signs. It includes entries for vital sign measurements as described in related profiles
This Section describes the travel history relevant for the Patient Summary, e.g.recent travel in a region of high prevalence of a specific infectious disease like Malaria
This section may provide both synthetic anamnesis ,e.g. description of phases of the pathology as a chronological summary of clustered clinical information, and anecdotal evidence that clinicians can collect from the patient, and can read in a narrative form.