HL7 Europe Hospital Discharge Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 0.0.1-ci built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/hdr/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr | Version: 0.0.1-ci | |||
Draft as of 2024-11-06 | Computable Name: CompositionEuHdr | |||
Copyright/Legal: Used by permission of HL7 Europe, all rights reserved Creative Commons License |
Clinical document used to represent a Hospital Discharge Report (HDR) for the scope of this guide.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |
value[x] | ||||
type | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |
identifier | 0..1 | Identifier | HDR business identifier | |
status | 1..1 | code | HDR status | |
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |
subject | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about | |
encounter | 0..1 | Reference(Encounter (HDR)) | Context of the Composition | |
date | 1..1 | dateTime | HDR date | |
Slices for author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() | |
author:practictionerRole | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition | |
title | 1..1 | string | Hospital Discharge Report | |
attester | ||||
mode | 1..1 | code | The type of attestation | |
time | 0..1 | dateTime | When the composition was attested. | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition. | |
Slices for section | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code | |
section:admissionEvaluationSection | 0..1 | BackboneElement | Hospital Admission evaluation | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
Slices for section | 0..* | Objective findings Slice: Unordered, Open by type:resolve() | ||
section:anthropometry | 0..1 | BackboneElement | Anthropometric observations | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Body measurements) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:vitalSigns | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
section | 0..0 | |||
section:physicalExamination | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
section | 0..0 | |||
section:functionalStatus | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section | 0..0 | |||
section:sectionHospitalCourse | 1..1 | BackboneElement | Significant information about course of hospital stay | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..1 | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
Slices for section | 5..* | Nested Section Slice: Unordered, Open by type:resolve() | ||
section:diagnosticSummaryDescription | 1..1 | BackboneElement | Problem specification in narrative form | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:significantProcedures | 1..1 | BackboneElement | Significant procedures | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Procedure) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:medicalDevices | 1..1 | BackboneElement | Medical devices and implants | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Device) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:medications | 1..1 | BackboneElement | Pharmacotherapy | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(MedicationStatement) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:significantResults | 0..1 | BackboneElement | Significant Observation Results | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Observation) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:synthesis | 1..1 | BackboneElement | Synthesis | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..0 | |||
emptyReason | 0..0 | |||
Slices for section | 2..* | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code | ||
section:problemSynthesis | 1..* | BackboneElement | Problem synthesis | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Condition) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:clinicalReasoning | 1..* | BackboneElement | Clinical reasoning | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:dischargeDetails | 1..1 | BackboneElement | Discharge details | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
Slices for section | 0..* | Objective findings Slice: Unordered, Open by type:resolve() | ||
section:anthropometry | 0..1 | BackboneElement | Anthropometric observations | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Body measurements) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:vitalSigns | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
section | 0..0 | |||
section:physicalExamination | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
section | 0..0 | |||
section:functionalStatus | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section | 0..0 | |||
section:patientHxSection | 0..1 | BackboneElement | Patient History Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (History general Narrative - Reported) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
section:sectionAllergies | 1..1 | BackboneElement | HDR Allergies and Intolerances Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Allergies and adverse reactions Document) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() | |
entry:allergyIntolerance | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry | |
emptyReason | 0..0 | |||
section:alertSection | 0..1 | BackboneElement | Health Concern Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Health concerns Document) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() | |
entry:flag | 0..1 | Reference(Flag) | Flags | |
entry:detectedIssue | 0..1 | Reference(DetectedIssue) | Detected Issue | |
entry:riskAssessment | 0..1 | Reference(RiskAssessment) | Risk Assessment | |
emptyReason | 0..0 | |||
section:sectionProceduresHx | 0..1 | BackboneElement | HDR History of Procedures Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() | |
entry:procedure | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry | |
emptyReason | 0..0 | |||
section:sectionImmunizations | 0..1 | BackboneElement | HDR Immunizations Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | |
entry:immunization | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry | |
emptyReason | 0..0 | |||
section:sectionPastIllnessHx | 0..1 | BackboneElement | HDR History of Past Illness Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (History of Past illness Narrative) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. | |
emptyReason | 0..0 | |||
section:CareTeamSection | 0..1 | BackboneElement | Care Team Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Patient Care team information) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() | |
entry:cteam | 0..1 | Reference(CareTeam) | Care Team | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:sectionPlanOfCare | 0..1 | BackboneElement | IPS Plan of Care Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Plan of care note) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionAdvanceDirectives | 0..1 | BackboneElement | IPS Advance Directives Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Advance directives) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionPayers | 0..1 | BackboneElement | Health insurance and payment information. | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Coverage) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionAttachments | 0..1 | BackboneElement | Attachments. | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact" | |
value[x] | 1..1 | RelatedArtifact | Value of extension | |
type | Σ | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Binding: RelatedArtifactType (required): The type of relationship to the related artifact. Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..1 | Identifier | HDR business identifier |
status | ?!Σ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |
subject | Σ | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter (HDR)) | Context of the Composition |
date | Σ | 1..1 | dateTime | HDR date |
Slices for author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() |
author:practictionerRole | Σ | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Hospital Discharge Report |
Slices for section | C | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
section:admissionEvaluationSection | C | 0..1 | BackboneElement | Hospital Admission evaluation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() |
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section:sectionHospitalCourse | C | 1..1 | BackboneElement | Significant information about course of hospital stay cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..1 | Reference(Resource) | A reference to data that supports this section |
Slices for section | C | 5..* | See section (Composition) | Nested Section Slice: Unordered, Open by type:resolve() |
section:diagnosticSummaryDescription | C | 1..1 | BackboneElement | Problem specification in narrative form |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:significantProcedures | C | 1..1 | BackboneElement | Significant procedures |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Procedure) | A reference to data that supports this section |
section:medicalDevices | C | 1..1 | BackboneElement | Medical devices and implants |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Device) | A reference to data that supports this section |
section:medications | C | 1..1 | BackboneElement | Pharmacotherapy |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(MedicationStatement) | A reference to data that supports this section |
section:significantResults | C | 0..1 | BackboneElement | Significant Observation Results |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Observation) | A reference to data that supports this section |
section:synthesis | C | 1..1 | BackboneElement | Synthesis |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 2..* | See section (Composition) | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code |
section:problemSynthesis | C | 1..* | BackboneElement | Problem synthesis |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section |
section:clinicalReasoning | C | 1..* | BackboneElement | Clinical reasoning |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
section:dischargeDetails | C | 1..1 | BackboneElement | Discharge details cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() |
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section:patientHxSection | C | 0..1 | BackboneElement | Patient History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History general Narrative - Reported) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionAllergies | C | 1..1 | BackboneElement | HDR Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Allergies and adverse reactions Document) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() |
entry:allergyIntolerance | C | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry |
section:alertSection | C | 0..1 | BackboneElement | Health Concern Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Health concerns Document) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() |
entry:flag | C | 0..1 | Reference(Flag) | Flags |
entry:detectedIssue | C | 0..1 | Reference(DetectedIssue) | Detected Issue |
entry:riskAssessment | C | 0..1 | Reference(RiskAssessment) | Risk Assessment |
section:sectionProceduresHx | C | 0..1 | BackboneElement | HDR History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() |
entry:procedure | C | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry |
section:sectionImmunizations | C | 0..1 | BackboneElement | HDR Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() |
entry:immunization | C | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry |
section:sectionPastIllnessHx | C | 0..1 | BackboneElement | HDR History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History of Past illness Narrative) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. |
section:CareTeamSection | C | 0..1 | BackboneElement | Care Team Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Patient Care team information) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() |
entry:cteam | C | 0..1 | Reference(CareTeam) | Care Team |
section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Plan of care note) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section |
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Advance directives) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section |
section:sectionPayers | C | 0..1 | BackboneElement | Health insurance and payment information. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section |
section:sectionAttachments | C | 0..1 | BackboneElement | Attachments. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.extension:relatedArtifact.value[x].type | required | RelatedArtifactTypehttp://hl7.org/fhir/ValueSet/related-artifact-type|4.0.1 from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC Code 34105-7("Hospital Discharge summary")http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.code | example | Fixed Value: LOINC Code 67852-4("Hospital Admission evaluation note")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.code | example | Fixed Value: LOINC Code 8648-8("Hospital course Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:significantProcedures.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:medicalDevices.code | example | Fixed Value: SNOMED-CT Code 1184586001("Medical device document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:medications.code | example | Fixed Value: SNOMED-CT Code 1003606003("Medication history section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:significantResults.code | example | Fixed Value: SNOMED-CT Code 423100009("Results section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.code | example | Fixed Value: SNOMED-CT Code 423016009("Clinical statement entry (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.code | example | Fixed Value: LOINC Code 8650-4("Hospital discharge disposition Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:patientHxSection.code | example | Fixed Value: LOINC Code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Fixed Value: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:alertSection.code | example | Fixed Value: LOINC Code 75310-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Fixed Value: LOINC Code 47519-4("History of Procedures Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Fixed Value: LOINC Code 11369-6("History of Immunization Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Fixed Value: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:CareTeamSection.code | example | Fixed Value: LOINC Code 85847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPlanOfCare.code | example | Fixed Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.code | example | Fixed Value: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Fixed Value: LOINC Code 48768-6("Payment sources Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAttachments.code | example | Fixed Value: LOINC Code X-TBD-1("Attachments")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact" | |||||
value[x] | 1..1 | RelatedArtifact | Value of extension | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
type | Σ | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Binding: RelatedArtifactType (required): The type of relationship to the related artifact. Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} | ||||
label | Σ | 0..1 | string | Short label | ||||
display | Σ | 0..1 | string | Brief description of the related artifact | ||||
citation | Σ | 0..1 | markdown | Bibliographic citation for the artifact | ||||
url | Σ | 0..1 | url | Where the artifact can be accessed | ||||
document | Σ | 0..1 | Attachment | What document is being referenced | ||||
resource | Σ | 0..1 | canonical(Resource) | What resource is being referenced | ||||
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | HDR business identifier | ||||
status | ?!Σ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter (HDR)) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | HDR date | ||||
Slices for author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() | ||||
author:practictionerRole | Σ | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Hospital Discharge Report | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested. | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition. | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:admissionEvaluationSection | C | 0..1 | BackboneElement | Hospital Admission evaluation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() | ||||
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:sectionHospitalCourse | C | 1..1 | BackboneElement | Significant information about course of hospital stay cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..1 | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 5..* | See section (Composition) | Nested Section Slice: Unordered, Open by type:resolve() | ||||
section:diagnosticSummaryDescription | C | 1..1 | BackboneElement | Problem specification in narrative form | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
section:significantProcedures | C | 1..1 | BackboneElement | Significant procedures | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Procedure) | A reference to data that supports this section | ||||
section:medicalDevices | C | 1..1 | BackboneElement | Medical devices and implants | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Device) | A reference to data that supports this section | ||||
section:medications | C | 1..1 | BackboneElement | Pharmacotherapy | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(MedicationStatement) | A reference to data that supports this section | ||||
section:significantResults | C | 0..1 | BackboneElement | Significant Observation Results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation) | A reference to data that supports this section | ||||
section:synthesis | C | 1..1 | BackboneElement | Synthesis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for section | C | 2..* | See section (Composition) | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code | ||||
section:problemSynthesis | C | 1..* | BackboneElement | Problem synthesis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:clinicalReasoning | C | 1..* | BackboneElement | Clinical reasoning | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:dischargeDetails | C | 1..1 | BackboneElement | Discharge details cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() | ||||
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:patientHxSection | C | 0..1 | BackboneElement | Patient History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History general Narrative - Reported) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAllergies | C | 1..1 | BackboneElement | HDR Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Allergies and adverse reactions Document) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() | ||||
entry:allergyIntolerance | C | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:alertSection | C | 0..1 | BackboneElement | Health Concern Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Health concerns Document) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() | ||||
entry:flag | C | 0..1 | Reference(Flag) | Flags | ||||
entry:detectedIssue | C | 0..1 | Reference(DetectedIssue) | Detected Issue | ||||
entry:riskAssessment | C | 0..1 | Reference(RiskAssessment) | Risk Assessment | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionProceduresHx | C | 0..1 | BackboneElement | HDR History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() | ||||
entry:procedure | C | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionImmunizations | C | 0..1 | BackboneElement | HDR Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||
entry:immunization | C | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPastIllnessHx | C | 0..1 | BackboneElement | HDR History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History of Past illness Narrative) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:CareTeamSection | C | 0..1 | BackboneElement | Care Team Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Patient Care team information) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() | ||||
entry:cteam | C | 0..1 | Reference(CareTeam) | Care Team | ||||
section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Plan of care note) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Advance directives) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPayers | C | 0..1 | BackboneElement | Health insurance and payment information. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAttachments | C | 0..1 | BackboneElement | Attachments. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.extension:relatedArtifact.value[x].type | required | RelatedArtifactTypehttp://hl7.org/fhir/ValueSet/related-artifact-type|4.0.1 from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | Pattern: LOINC Code 34105-7("Hospital Discharge summary")http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.code | example | Fixed Value: LOINC Code 67852-4("Hospital Admission evaluation note")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.code | example | Fixed Value: LOINC Code 8648-8("Hospital course Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.code | example | Fixed Value: SNOMED-CT Code 1184586001("Medical device document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.code | example | Fixed Value: SNOMED-CT Code 1003606003("Medication history section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.code | example | Fixed Value: SNOMED-CT Code 423100009("Results section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.code | example | Fixed Value: SNOMED-CT Code 423016009("Clinical statement entry (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.code | example | Fixed Value: LOINC Code 8650-4("Hospital discharge disposition Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:patientHxSection.code | example | Fixed Value: LOINC Code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:patientHxSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:patientHxSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Fixed Value: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:alertSection.code | example | Fixed Value: LOINC Code 75310-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:alertSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:alertSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.code | example | Fixed Value: LOINC Code 47519-4("History of Procedures Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionImmunizations.code | example | Fixed Value: LOINC Code 11369-6("History of Immunization Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.code | example | Fixed Value: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:CareTeamSection.code | example | Fixed Value: LOINC Code 85847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:CareTeamSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:CareTeamSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.code | example | Fixed Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.code | example | Fixed Value: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPayers.code | example | Fixed Value: LOINC Code 48768-6("Payment sources Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPayers.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPayers.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAttachments.code | example | Fixed Value: LOINC Code X-TBD-1("Attachments")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAttachments.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAttachments.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 46 elements(52 nested mandatory elements)
Fixed: 24 elements
Prohibited: 39 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |
value[x] | ||||
type | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} | |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |
identifier | 0..1 | Identifier | HDR business identifier | |
status | 1..1 | code | HDR status | |
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |
subject | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about | |
encounter | 0..1 | Reference(Encounter (HDR)) | Context of the Composition | |
date | 1..1 | dateTime | HDR date | |
Slices for author | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() | |
author:practictionerRole | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition | |
title | 1..1 | string | Hospital Discharge Report | |
attester | ||||
mode | 1..1 | code | The type of attestation | |
time | 0..1 | dateTime | When the composition was attested. | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition. | |
Slices for section | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code | |
section:admissionEvaluationSection | 0..1 | BackboneElement | Hospital Admission evaluation | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
Slices for section | 0..* | Objective findings Slice: Unordered, Open by type:resolve() | ||
section:anthropometry | 0..1 | BackboneElement | Anthropometric observations | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Body measurements) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:vitalSigns | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
section | 0..0 | |||
section:physicalExamination | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
section | 0..0 | |||
section:functionalStatus | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section | 0..0 | |||
section:sectionHospitalCourse | 1..1 | BackboneElement | Significant information about course of hospital stay | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..1 | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
Slices for section | 5..* | Nested Section Slice: Unordered, Open by type:resolve() | ||
section:diagnosticSummaryDescription | 1..1 | BackboneElement | Problem specification in narrative form | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:significantProcedures | 1..1 | BackboneElement | Significant procedures | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Procedure) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:medicalDevices | 1..1 | BackboneElement | Medical devices and implants | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Device) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:medications | 1..1 | BackboneElement | Pharmacotherapy | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(MedicationStatement) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:significantResults | 0..1 | BackboneElement | Significant Observation Results | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Observation) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:synthesis | 1..1 | BackboneElement | Synthesis | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..0 | |||
emptyReason | 0..0 | |||
Slices for section | 2..* | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code | ||
section:problemSynthesis | 1..* | BackboneElement | Problem synthesis | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Condition) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:clinicalReasoning | 1..* | BackboneElement | Clinical reasoning | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:dischargeDetails | 1..1 | BackboneElement | Discharge details | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
Slices for section | 0..* | Objective findings Slice: Unordered, Open by type:resolve() | ||
section:anthropometry | 0..1 | BackboneElement | Anthropometric observations | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Body measurements) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:vitalSigns | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | 1..* | Reference(Resource) | A reference to data that supports this section | |
section | 0..0 | |||
section:physicalExamination | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
section | 0..0 | |||
section:functionalStatus | 0..1 | BackboneElement | Nested Section | |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section | 0..0 | |||
section:patientHxSection | 0..1 | BackboneElement | Patient History Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (History general Narrative - Reported) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
emptyReason | 0..0 | |||
section:sectionAllergies | 1..1 | BackboneElement | HDR Allergies and Intolerances Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Allergies and adverse reactions Document) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() | |
entry:allergyIntolerance | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry | |
emptyReason | 0..0 | |||
section:alertSection | 0..1 | BackboneElement | Health Concern Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Health concerns Document) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() | |
entry:flag | 0..1 | Reference(Flag) | Flags | |
entry:detectedIssue | 0..1 | Reference(DetectedIssue) | Detected Issue | |
entry:riskAssessment | 0..1 | Reference(RiskAssessment) | Risk Assessment | |
emptyReason | 0..0 | |||
section:sectionProceduresHx | 0..1 | BackboneElement | HDR History of Procedures Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() | |
entry:procedure | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry | |
emptyReason | 0..0 | |||
section:sectionImmunizations | 0..1 | BackboneElement | HDR Immunizations Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | |
entry:immunization | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry | |
emptyReason | 0..0 | |||
section:sectionPastIllnessHx | 0..1 | BackboneElement | HDR History of Past Illness Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (History of Past illness Narrative) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. | |
emptyReason | 0..0 | |||
section:CareTeamSection | 0..1 | BackboneElement | Care Team Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Patient Care team information) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
Slices for entry | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() | |
entry:cteam | 0..1 | Reference(CareTeam) | Care Team | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:sectionPlanOfCare | 0..1 | BackboneElement | IPS Plan of Care Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Plan of care note) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionAdvanceDirectives | 0..1 | BackboneElement | IPS Advance Directives Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown (Advance directives) | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionPayers | 0..1 | BackboneElement | Health insurance and payment information. | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(Coverage) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
section:sectionAttachments | 0..1 | BackboneElement | Attachments. | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Fixed Value: As shown | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |
text | 1..1 | Narrative | Text summary of the section, for human interpretation | |
entry | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section | |
emptyReason | 0..0 | |||
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact" | |
value[x] | 1..1 | RelatedArtifact | Value of extension | |
type | Σ | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Binding: RelatedArtifactType (required): The type of relationship to the related artifact. Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} |
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..1 | Identifier | HDR business identifier |
status | ?!Σ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |
subject | Σ | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter (HDR)) | Context of the Composition |
date | Σ | 1..1 | dateTime | HDR date |
Slices for author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() |
author:practictionerRole | Σ | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Hospital Discharge Report |
Slices for section | C | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
section:admissionEvaluationSection | C | 0..1 | BackboneElement | Hospital Admission evaluation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() |
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section:sectionHospitalCourse | C | 1..1 | BackboneElement | Significant information about course of hospital stay cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..1 | Reference(Resource) | A reference to data that supports this section |
Slices for section | C | 5..* | See section (Composition) | Nested Section Slice: Unordered, Open by type:resolve() |
section:diagnosticSummaryDescription | C | 1..1 | BackboneElement | Problem specification in narrative form |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:significantProcedures | C | 1..1 | BackboneElement | Significant procedures |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Procedure) | A reference to data that supports this section |
section:medicalDevices | C | 1..1 | BackboneElement | Medical devices and implants |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Device) | A reference to data that supports this section |
section:medications | C | 1..1 | BackboneElement | Pharmacotherapy |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(MedicationStatement) | A reference to data that supports this section |
section:significantResults | C | 0..1 | BackboneElement | Significant Observation Results |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Observation) | A reference to data that supports this section |
section:synthesis | C | 1..1 | BackboneElement | Synthesis |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 2..* | See section (Composition) | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code |
section:problemSynthesis | C | 1..* | BackboneElement | Problem synthesis |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section |
section:clinicalReasoning | C | 1..* | BackboneElement | Clinical reasoning |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
section:dischargeDetails | C | 1..1 | BackboneElement | Discharge details cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() |
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section |
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |
section:patientHxSection | C | 0..1 | BackboneElement | Patient History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History general Narrative - Reported) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionAllergies | C | 1..1 | BackboneElement | HDR Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Allergies and adverse reactions Document) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() |
entry:allergyIntolerance | C | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry |
section:alertSection | C | 0..1 | BackboneElement | Health Concern Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Health concerns Document) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() |
entry:flag | C | 0..1 | Reference(Flag) | Flags |
entry:detectedIssue | C | 0..1 | Reference(DetectedIssue) | Detected Issue |
entry:riskAssessment | C | 0..1 | Reference(RiskAssessment) | Risk Assessment |
section:sectionProceduresHx | C | 0..1 | BackboneElement | HDR History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() |
entry:procedure | C | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry |
section:sectionImmunizations | C | 0..1 | BackboneElement | HDR Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() |
entry:immunization | C | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry |
section:sectionPastIllnessHx | C | 0..1 | BackboneElement | HDR History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History of Past illness Narrative) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. |
section:CareTeamSection | C | 0..1 | BackboneElement | Care Team Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Patient Care team information) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
Slices for entry | C | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() |
entry:cteam | C | 0..1 | Reference(CareTeam) | Care Team |
section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Plan of care note) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section |
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Advance directives) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
display | 0..0 | string | Representation defined by the system | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section |
section:sectionPayers | C | 0..1 | BackboneElement | Health insurance and payment information. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section |
section:sectionAttachments | C | 0..1 | BackboneElement | Attachments. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation |
entry | C | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.extension:relatedArtifact.value[x].type | required | RelatedArtifactTypehttp://hl7.org/fhir/ValueSet/related-artifact-type|4.0.1 from the FHIR Standard | |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC Code 34105-7("Hospital Discharge summary")http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.code | example | Fixed Value: LOINC Code 67852-4("Hospital Admission evaluation note")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:admissionEvaluationSection.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.code | example | Fixed Value: LOINC Code 8648-8("Hospital course Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:significantProcedures.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:medicalDevices.code | example | Fixed Value: SNOMED-CT Code 1184586001("Medical device document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:medications.code | example | Fixed Value: SNOMED-CT Code 1003606003("Medication history section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:significantResults.code | example | Fixed Value: SNOMED-CT Code 423100009("Results section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.code | example | Fixed Value: SNOMED-CT Code 423016009("Clinical statement entry (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.code | example | Fixed Value: LOINC Code 8650-4("Hospital discharge disposition Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:dischargeDetails.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:patientHxSection.code | example | Fixed Value: LOINC Code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Fixed Value: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:alertSection.code | example | Fixed Value: LOINC Code 75310-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Fixed Value: LOINC Code 47519-4("History of Procedures Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Fixed Value: LOINC Code 11369-6("History of Immunization Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Fixed Value: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:CareTeamSection.code | example | Fixed Value: LOINC Code 85847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPlanOfCare.code | example | Fixed Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.code | example | Fixed Value: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPayers.code | example | Fixed Value: LOINC Code 48768-6("Payment sources Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAttachments.code | example | Fixed Value: LOINC Code X-TBD-1("Attachments")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | Hospital Discharge Report composition | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
basedOn | 0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||
value[x] | 1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||
relatedArtifact | 0..* | (Complex) | Related artefacts: e.g. presented form URL: http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact | |||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/artifact-relatedArtifact" | |||||
value[x] | 1..1 | RelatedArtifact | Value of extension | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
type | Σ | 1..1 | code | documentation | justification | citation | predecessor | successor | derived-from | depends-on | composed-of Binding: RelatedArtifactType (required): The type of relationship to the related artifact. Example presented form: {"coding":[{"system":"http://hl7.org/fhir/related-artifact-type","code":"transformed-into"}]} | ||||
label | Σ | 0..1 | string | Short label | ||||
display | Σ | 0..1 | string | Brief description of the related artifact | ||||
citation | Σ | 0..1 | markdown | Bibliographic citation for the artifact | ||||
url | Σ | 0..1 | url | Where the artifact can be accessed | ||||
document | Σ | 0..1 | Attachment | What document is being referenced | ||||
resource | Σ | 0..1 | canonical(Resource) | What resource is being referenced | ||||
information-recipient | 0..* | (Complex) | Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||
value[x] | 0..1 | Reference(PractitionerRole: (HDR) | Practitioner (HDR) | Device | Patient (HDR) | RelatedPerson | Organization) | Value of extension | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | HDR business identifier | ||||
status | ?!Σ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | 1..1 | CodeableConceptIPS(2.0.0) | Kind of composition ("Hospital Discharge Report") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Discharge summary | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 1..1 | Reference(Patient (HDR)) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter (HDR)) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | HDR date | ||||
Slices for author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Sliced per type of author Slice: Unordered, Open by type:valueReference.resolve() | ||||
author:practictionerRole | Σ | 0..* | Reference(PractitionerRole: (HDR)) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Hospital Discharge Report | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested. | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition. | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 3..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:admissionEvaluationSection | C | 0..1 | BackboneElement | Hospital Admission evaluation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67852-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital Admission evaluation note | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() | ||||
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:sectionHospitalCourse | C | 1..1 | BackboneElement | Significant information about course of hospital stay cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital course Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..1 | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 5..* | See section (Composition) | Nested Section Slice: Unordered, Open by type:resolve() | ||||
section:diagnosticSummaryDescription | C | 1..1 | BackboneElement | Problem specification in narrative form | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
section:significantProcedures | C | 1..1 | BackboneElement | Significant procedures | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Diagnostic studies report (record artifact)) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Procedure) | A reference to data that supports this section | ||||
section:medicalDevices | C | 1..1 | BackboneElement | Medical devices and implants | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184586001 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Medical device document section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Device) | A reference to data that supports this section | ||||
section:medications | C | 1..1 | BackboneElement | Pharmacotherapy | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(MedicationStatement) | A reference to data that supports this section | ||||
section:significantResults | C | 0..1 | BackboneElement | Significant Observation Results | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423100009 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Results section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Observation) | A reference to data that supports this section | ||||
section:synthesis | C | 1..1 | BackboneElement | Synthesis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for section | C | 2..* | See section (Composition) | Subsections of the Hospital Discharge Report Synthesis Slice: Unordered, Open by value:code | ||||
section:problemSynthesis | C | 1..* | BackboneElement | Problem synthesis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 423016009 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical statement entry (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:clinicalReasoning | C | 1..* | BackboneElement | Clinical reasoning | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 424836000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Assessment section (record artifact) | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:dischargeDetails | C | 1..1 | BackboneElement | Discharge details cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Hospital discharge disposition Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
Slices for section | C | 0..* | See section (Composition) | Objective findings Slice: Unordered, Open by type:resolve() | ||||
section:anthropometry | C | 0..1 | BackboneElement | Anthropometric observations | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Body measurements) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 248326004 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
section:vitalSigns | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184593002 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Vital sign document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:physicalExamination | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Physical examination | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:functionalStatus | C | 0..1 | BackboneElement | Nested Section | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) Required Pattern: Functional status assessment | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1184588000 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Functional status document section (record artifact) | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:patientHxSection | C | 0..1 | BackboneElement | Patient History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History general Narrative - Reported) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAllergies | C | 1..1 | BackboneElement | HDR Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Allergies and adverse reactions Document) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by type:resolve() | ||||
entry:allergyIntolerance | C | 0..1 | Reference(AllergyIntolerance (IPS)(2.0.0)) | HDR Allergy entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:alertSection | C | 0..1 | BackboneElement | Health Concern Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Health concerns Document) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75310-3 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | Alerts Slice: Unordered, Open by type:resolve() | ||||
entry:flag | C | 0..1 | Reference(Flag) | Flags | ||||
entry:detectedIssue | C | 0..1 | Reference(DetectedIssue) | Detected Issue | ||||
entry:riskAssessment | C | 0..1 | Reference(RiskAssessment) | Risk Assessment | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionProceduresHx | C | 0..1 | BackboneElement | HDR History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: History of Procedures Document | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by type:resolve() | ||||
entry:procedure | C | 0..1 | Reference(Procedure (IPS)(2.0.0)) | Past Procedure entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionImmunizations | C | 0..1 | BackboneElement | HDR Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: History of Immunization Narrative | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||
entry:immunization | C | 0..1 | Reference(Immunization (IPS)(2.0.0)) | Immunization entry | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPastIllnessHx | C | 0..1 | BackboneElement | HDR History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (History of Past illness Narrative) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 1..* | Reference(Condition (IPS)(2.0.0)) | Conditions the patient suffered in the past. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:CareTeamSection | C | 0..1 | BackboneElement | Care Team Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Patient Care team information) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85847-2 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Resource) | Care Teams Slice: Unordered, Open by type:resolve() | ||||
entry:cteam | C | 0..1 | Reference(CareTeam) | Care Team | ||||
section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Plan of care note) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(CarePlan | DocumentReference) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown (Advance directives) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
display | 0..0 | string | Representation defined by the system | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Consent | DocumentReference) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionPayers | C | 0..1 | BackboneElement | Health insurance and payment information. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Payment sources Document | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionAttachments | C | 0..1 | BackboneElement | Attachments. cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 1..1 | string | Label for section (e.g. for ToC) | |||||
code | 1..1 | CodeableConceptIPS(2.0.0) | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Fixed Value: As shown | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: X-TBD-1 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Attachments | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.extension:relatedArtifact.value[x].type | required | RelatedArtifactTypehttp://hl7.org/fhir/ValueSet/related-artifact-type|4.0.1 from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | Pattern: LOINC Code 34105-7("Hospital Discharge summary")http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.code | example | Fixed Value: LOINC Code 67852-4("Hospital Admission evaluation note")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:anthropometry.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:vitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:physicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:admissionEvaluationSection.section:functionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.code | example | Fixed Value: LOINC Code 8648-8("Hospital course Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:diagnosticSummaryDescription.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.code | example | Fixed Value: SNOMED-CT Code 721981007http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantProcedures.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.code | example | Fixed Value: SNOMED-CT Code 1184586001("Medical device document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medicalDevices.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.code | example | Fixed Value: SNOMED-CT Code 1003606003("Medication history section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:medications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.code | example | Fixed Value: SNOMED-CT Code 423100009("Results section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:significantResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.code | example | Fixed Value: SNOMED-CT Code 423016009("Clinical statement entry (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:problemSynthesis.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.code | example | Fixed Value: SNOMED-CT Code 424836000("Assessment section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionHospitalCourse.section:synthesis.section:clinicalReasoning.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.code | example | Fixed Value: LOINC Code 8650-4("Hospital discharge disposition Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.code | example | Fixed Value: SNOMED-CT Code 248326004http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:anthropometry.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.code | example | Pattern: SNOMED-CT Code 1184593002("Vital sign document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:vitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.code | example | Pattern: SNOMED-CT Code 425044008("Physical exam section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:physicalExamination.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.code | example | Pattern: SNOMED-CT Code 1184588000("Functional status document section (record artifact)")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:dischargeDetails.section:functionalStatus.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:patientHxSection.code | example | Fixed Value: LOINC Code 11329-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:patientHxSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:patientHxSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Fixed Value: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:alertSection.code | example | Fixed Value: LOINC Code 75310-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:alertSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:alertSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.code | example | Fixed Value: LOINC Code 47519-4("History of Procedures Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionImmunizations.code | example | Fixed Value: LOINC Code 11369-6("History of Immunization Narrative")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.code | example | Fixed Value: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:CareTeamSection.code | example | Fixed Value: LOINC Code 85847-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:CareTeamSection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:CareTeamSection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.code | example | Fixed Value: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.code | example | Fixed Value: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPayers.code | example | Fixed Value: LOINC Code 48768-6("Payment sources Document")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPayers.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPayers.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAttachments.code | example | Fixed Value: LOINC Code X-TBD-1("Attachments")http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAttachments.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAttachments.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:admissionEvaluationSection, Composition.section:sectionHospitalCourse, Composition.section:dischargeDetails, Composition.section:patientHxSection, Composition.section:sectionAllergies, Composition.section:alertSection, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionPastIllnessHx, Composition.section:CareTeamSection, Composition.section:sectionPlanOfCare, Composition.section:sectionAdvanceDirectives, Composition.section:sectionPayers, Composition.section:sectionAttachments | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 46 elements(52 nested mandatory elements)
Fixed: 24 elements
Prohibited: 39 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron