HL7 Europe Hospital Discharge Report
1.0.0-ci - draft
150
HL7 Europe Hospital Discharge Report
1.0.0-ci - draft
150
HL7 Europe Hospital Discharge Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 1.0.0-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-obl-eu-hdr | Version: 1.0.0-ci | |||
| Standards status: Informative | Maturity Level: 0 | Computable Name: CompositionEuHdrObligation | ||
Copyright/Legal: Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0). |
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This profile defines obligations for a Hospital Discharge Report (HDR) for the scope of this guide.
Medication ListsThe usage of several resources for expressing medication is related to the different purposes and meaning of each resource. While more clear boundaries and relationships between resources may be useful, the editors have decided to maintain a comprehensive set of options open. Reviewers are invited to provide their feedback about the usage of the Medication related resources (e.g. MedicationStatement, MedicationRequest,...) in the medication lists used by the HDR
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
  Composition |
C | 0..* | CompositionEuHdr | Hospital Discharge Report composition Constraints: text-or-section | ||||||||
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
O | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
  Slices for extension |
Content/Rules for all slices | |||||||||||
   extension:basedOn |
0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||||||
   extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||||||
  value[x] |
1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||||||
 extension:version |
0..1 | string | Business version URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version Constraints: ext-1 | |||||||||
 extension:information-recipient |
0..* | (Complex) | Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||||||
 extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
 identifier |
OΣ | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
?!OΣ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
| ||||||||
| type |
OΣ | 1..1 | CodeableConcept | 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 |
0..1 | string | Representation defined by the system | |||||||||
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| category |
OΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Example Document category: {"system":"http://loinc.org","code":"LP72467-1","display":"Discharge summary note"}
| ||||||||
| subject |
OΣ | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
OΣ | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
OΣ | 1..1 | dateTime | HDR date
| ||||||||
| author |
OΣ | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
OΣ | 1..1 | string | Hospital Discharge Report
| ||||||||
| attester |
O | 0..* | BackboneElement | Attests to accuracy of composition
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
O | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
OΣ | 0..1 | Reference(Organization) | Organization which maintains the composition
| ||||||||
 Slices for section |
OC | 1..* | BackboneElement | Sections composing the HDR Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
| ||||||||
 section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
 extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| 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 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionAlert |
OC | 0..1 | BackboneElement | Substantial alerts and warnings Constraints: cmp-1, cmp-2
| ||||||||
 Slices for extension |
Content/Rules for all slices | |||||||||||
 extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Alerts" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 104605-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| Slices for entry |
OC | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry Slice: Unordered, Open by type:resolve()
| ||||||||
 Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
OC | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| section:sectionAdmissionEvaluation |
OC | 0..1 | BackboneElement | Patient evaluation at hospital admission Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital admission evaluation" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67851-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionVitalSigns |
C | 0..1 | BackboneElement | Vital signs during the encounter and at discharge Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Vital signs" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
C | 0..* | Reference(Observation: obligations | DocumentReference | Vital Signs Profile) | A reference to data that supports this section | ||||||||
| section:sectionPhysicalFindings |
OC | 0..1 | BackboneElement | Objective findings from physical examination Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Physical findings" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Observation: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionFunctionalStatus |
OC | 0..1 | BackboneElement | Ability to perform activities of daily living Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Functional status" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
OC | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
OC | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| section:sectionHospitalCourse |
OC | 1..1 | BackboneElement | Significant information about course of hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital course" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionDiagnosticSummary |
OC | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Diagnostic summary" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantProcedures |
OC | 0..1 | BackboneElement | Significant procedures performed during the stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10185-7 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionMedicalDevices |
OC | 0..1 | BackboneElement | Devices used or implanted before this encounter Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of medical device use" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
OC | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| section:sectionProceduresHx |
OC | 0..1 | BackboneElement | Past procedures relevant to this encounter Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
OC | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| section:sectionPharmacotherapy |
OC | 0..1 | BackboneElement | Drug treatment discontinued before discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Pharmacotherapy" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 87232-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
OC | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| section:sectionImplantedDevices |
OC | 0..1 | BackboneElement | Devices and implants during the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Medical devices and implants" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57080-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantResults |
OC | 0..1 | BackboneElement | Significant medical test results of the stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant medical test results" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
OC | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
OC | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| section:sectionSynthesis |
OC | 0..1 | BackboneElement | Clinical synthesis of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Synthesis" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67781-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionPlanOfCare |
OC | 0..1 | BackboneElement | Plan of care and recommendations after discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Plan of care" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| entry |
OC | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeMedications |
OC | 0..1 | BackboneElement | Medication intended after discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital discharge medications" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 75311-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| entry |
OC | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionAllergies |
C | 0..1 | BackboneElement | Relevant allergies and intolerances Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Allergies and intolerances" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
C | 0..* | Reference(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
OC | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| section:sectionPatientHx |
OC | 0..1 | BackboneElement | Narrative patient health history (anamnesis) Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Patient health history" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionProblems |
OC | 0..1 | BackboneElement | Problems currently being monitored Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Problem list" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
OC | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionImmunizations |
C | 0..1 | BackboneElement | Immunization status and vaccination history Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Immunizations" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
C | 0..* | Reference(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
OC | 0..* | Reference(Immunization: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeDetails |
OC | 0..1 | BackboneElement | Discharge status and disposition of the patient Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Discharge details" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionAttachments |
C | 0..1 | BackboneElement | Library of attachments Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Attachments" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 77599-9 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.section.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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()
|
| text-or-section | error | Composition | A Composition SHALL have either text, at least one section, or both. |
text.exists() or section.exists()
|
This structure is derived from CompositionEuHdr
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
CompositionEuHdr | |||||||||||
| language |
O | 0..1 | code | Language of the resource content
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:information-recipient |
0..* | InformationRecipient | Composition: Information recipient | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
| identifier |
O | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
O | 1..1 | code | HDR status
| ||||||||
| type |
O | 1..1 | CodeableConcept | Kind of composition ("Hospital Discharge Report")
| ||||||||
| category |
O | 0..* | CodeableConcept | Categorization of Composition
| ||||||||
| subject |
O | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
O | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
O | 1..1 | dateTime | HDR date
| ||||||||
| author |
O | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
O | 1..1 | string | Hospital Discharge Report
| ||||||||
| attester |
O | 0..* | BackboneElement | Attests to accuracy of composition
| ||||||||
| mode |
O | 1..1 | code | The type of attestation
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
O | 0..1 | Reference(Organization) | Organization which maintains the composition
| ||||||||
| event |
||||||||||||
| period |
O | 0..1 | Period | The period covered by the documentation
| ||||||||
| section |
O | 1..* | BackboneElement | Sections composing the HDR
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| Slices for section |
Content/Rules for all slices | |||||||||||
| section:sectionAlert |
O | 0..1 | BackboneElement | Substantial alerts and warnings
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
O | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| section:sectionAdmissionEvaluation |
O | 0..1 | BackboneElement | Patient evaluation at hospital admission
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionVitalSigns |
0..1 | BackboneElement | Vital signs during the encounter and at discharge | |||||||||
| entry |
0..* | Reference(Observation: obligations | DocumentReference | Vital Signs Profile) | A reference to data that supports this section | |||||||||
| section:sectionPhysicalFindings |
O | 0..1 | BackboneElement | Objective findings from physical examination
| ||||||||
| entry |
O | 0..* | Reference(Observation: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionFunctionalStatus |
O | 0..1 | BackboneElement | Ability to perform activities of daily living
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
O | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
O | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| section:sectionHospitalCourse |
O | 1..1 | BackboneElement | Significant information about course of hospital stay
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionDiagnosticSummary |
O | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantProcedures |
O | 0..1 | BackboneElement | Significant procedures performed during the stay
| ||||||||
| entry |
O | 0..* | Reference(Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionMedicalDevices |
O | 0..1 | BackboneElement | Devices used or implanted before this encounter
| ||||||||
| entry |
O | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
O | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| section:sectionProceduresHx |
O | 0..1 | BackboneElement | Past procedures relevant to this encounter
| ||||||||
| entry |
O | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
O | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| section:sectionPharmacotherapy |
O | 0..1 | BackboneElement | Drug treatment discontinued before discharge
| ||||||||
| entry |
O | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
O | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| section:sectionImplantedDevices |
O | 0..1 | BackboneElement | Devices and implants during the hospital stay
| ||||||||
| entry |
O | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantResults |
O | 0..1 | BackboneElement | Significant medical test results of the stay
| ||||||||
| entry |
O | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
O | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
O | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| section:sectionSynthesis |
O | 0..1 | BackboneElement | Clinical synthesis of the hospital stay
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionPlanOfCare |
O | 0..1 | BackboneElement | Plan of care and recommendations after discharge
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeMedications |
O | 0..1 | BackboneElement | Medication intended after discharge
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionAllergies |
0..1 | BackboneElement | Relevant allergies and intolerances | |||||||||
| entry |
0..* | Reference(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance | |||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
O | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| section:sectionPatientHx |
O | 0..1 | BackboneElement | Narrative patient health history (anamnesis)
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionProblems |
O | 0..1 | BackboneElement | Problems currently being monitored
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient.
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
O | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionImmunizations |
0..1 | BackboneElement | Immunization status and vaccination history | |||||||||
| entry |
0..* | Reference(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. | |||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
O | 0..* | Reference(Immunization: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeDetails |
O | 0..1 | BackboneElement | Discharge status and disposition of the patient
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionAttachments |
0..1 | BackboneElement | Library of attachments | |||||||||
| entry |
O | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| Documentation for this format | ||||||||||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | CompositionEuHdr | Hospital Discharge Report composition Constraints: text-or-section | ||||||||
| 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 |
O | 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:basedOn |
0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||||||
| value[x] |
1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||||||
| extension:version |
0..1 | string | Business version URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version Constraints: ext-1 | |||||||||
| extension:information-recipient |
0..* | (Complex) | Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| identifier |
OΣ | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
?!OΣ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
| ||||||||
| type |
OΣ | 1..1 | CodeableConcept | 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 Slice: Unordered, Open by value:url | |||||||||
| coding |
Σ | 0..* | 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 Slice: Unordered, Open by value:url | |||||||||
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | ||||||||
| display |
Σ | 1..1 | string | Representation defined by the system | ||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||||||
| category |
OΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Example Document category: {"system":"http://loinc.org","code":"LP72467-1","display":"Discharge summary note"}
| ||||||||
| subject |
OΣ | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
OΣ | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
OΣ | 1..1 | dateTime | HDR date
| ||||||||
| author |
OΣ | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
OΣ | 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 |
O | 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 |
O | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
OΣ | 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 |
OΣ | 0..1 | Period | The period covered by the documentation
| ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| Slices for section |
OC | 1..* | BackboneElement | Sections composing the HDR Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
| ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| 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 | 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 |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionAlert |
OC | 0..1 | BackboneElement | Substantial alerts and warnings Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Alerts" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 104605-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
OC | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| 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:sectionAdmissionEvaluation |
OC | 0..1 | BackboneElement | Patient evaluation at hospital admission Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital admission evaluation" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67851-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionVitalSigns |
C | 0..1 | BackboneElement | Vital signs during the encounter and at discharge Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Vital signs" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Observation: obligations | DocumentReference | Vital Signs Profile) | 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:sectionPhysicalFindings |
OC | 0..1 | BackboneElement | Objective findings from physical examination Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Physical findings" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Observation: obligations | DocumentReference) | 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:sectionFunctionalStatus |
OC | 0..1 | BackboneElement | Ability to perform activities of daily living Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Functional status" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
OC | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
OC | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionHospitalCourse |
OC | 1..1 | BackboneElement | Significant information about course of hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital course" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionDiagnosticSummary |
OC | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Diagnostic summary" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations) | 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:sectionSignificantProcedures |
OC | 0..1 | BackboneElement | Significant procedures performed during the stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10185-7 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Procedure: obligations) | 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:sectionMedicalDevices |
OC | 0..1 | BackboneElement | Devices used or implanted before this encounter Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of medical device use" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
OC | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| 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:sectionProceduresHx |
OC | 0..1 | BackboneElement | Past procedures relevant to this encounter Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
OC | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| 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:sectionPharmacotherapy |
OC | 0..1 | BackboneElement | Drug treatment discontinued before discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Pharmacotherapy" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 87232-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
OC | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| 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:sectionImplantedDevices |
OC | 0..1 | BackboneElement | Devices and implants during the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Medical devices and implants" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57080-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | 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:sectionSignificantResults |
OC | 0..1 | BackboneElement | Significant medical test results of the stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant medical test results" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
OC | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
OC | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| 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:sectionSynthesis |
OC | 0..1 | BackboneElement | Clinical synthesis of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Synthesis" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67781-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionPlanOfCare |
OC | 0..1 | BackboneElement | Plan of care and recommendations after discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Plan of care" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionDischargeMedications |
OC | 0..1 | BackboneElement | Medication intended after discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital discharge medications" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 75311-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionAllergies |
C | 0..1 | BackboneElement | Relevant allergies and intolerances Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Allergies and intolerances" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
OC | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| 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:sectionPatientHx |
OC | 0..1 | BackboneElement | Narrative patient health history (anamnesis) Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Patient health history" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionProblems |
OC | 0..1 | BackboneElement | Problems currently being monitored Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Problem list" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
OC | 0..* | Reference(Condition: obligations) | 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:sectionImmunizations |
C | 0..1 | BackboneElement | Immunization status and vaccination history Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Immunizations" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
OC | 0..* | Reference(Immunization: obligations) | 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:sectionDischargeDetails |
OC | 0..1 | BackboneElement | Discharge status and disposition of the patient Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Discharge details" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionAttachments |
C | 0..1 | BackboneElement | Library of attachments Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Attachments" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 77599-9 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std. |
| Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.3 |
| Composition.section.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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()
|
| text-or-section | error | Composition | A Composition SHALL have either text, at least one section, or both. |
text.exists() or section.exists()
|
This structure is derived from CompositionEuHdr
Summary
Structures
This structure refers to these other structures:
Maturity: 0
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | CompositionEuHdr | Hospital Discharge Report composition Constraints: text-or-section | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
O | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:basedOn |
0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||||||
| value[x] |
1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||||||
| extension:version |
0..1 | string | Business version URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version Constraints: ext-1 | |||||||||
| extension:information-recipient |
0..* | (Complex) | Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| identifier |
OΣ | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
?!OΣ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
| ||||||||
| type |
OΣ | 1..1 | CodeableConcept | 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 |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| category |
OΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Example Document category: {"system":"http://loinc.org","code":"LP72467-1","display":"Discharge summary note"}
| ||||||||
| subject |
OΣ | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
OΣ | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
OΣ | 1..1 | dateTime | HDR date
| ||||||||
| author |
OΣ | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
OΣ | 1..1 | string | Hospital Discharge Report
| ||||||||
| attester |
O | 0..* | BackboneElement | Attests to accuracy of composition
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| mode |
O | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
OΣ | 0..1 | Reference(Organization) | Organization which maintains the composition
| ||||||||
| Slices for section |
OC | 1..* | BackboneElement | Sections composing the HDR Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
| ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| 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 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionAlert |
OC | 0..1 | BackboneElement | Substantial alerts and warnings Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Alerts" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 104605-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| Slices for entry |
OC | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
OC | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| section:sectionAdmissionEvaluation |
OC | 0..1 | BackboneElement | Patient evaluation at hospital admission Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital admission evaluation" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67851-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionVitalSigns |
C | 0..1 | BackboneElement | Vital signs during the encounter and at discharge Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Vital signs" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
C | 0..* | Reference(Observation: obligations | DocumentReference | Vital Signs Profile) | A reference to data that supports this section | ||||||||
| section:sectionPhysicalFindings |
OC | 0..1 | BackboneElement | Objective findings from physical examination Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Physical findings" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Observation: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionFunctionalStatus |
OC | 0..1 | BackboneElement | Ability to perform activities of daily living Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Functional status" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
OC | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
OC | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| section:sectionHospitalCourse |
OC | 1..1 | BackboneElement | Significant information about course of hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital course" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionDiagnosticSummary |
OC | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Diagnostic summary" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantProcedures |
OC | 0..1 | BackboneElement | Significant procedures performed during the stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10185-7 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionMedicalDevices |
OC | 0..1 | BackboneElement | Devices used or implanted before this encounter Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of medical device use" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
OC | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| section:sectionProceduresHx |
OC | 0..1 | BackboneElement | Past procedures relevant to this encounter Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
OC | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| section:sectionPharmacotherapy |
OC | 0..1 | BackboneElement | Drug treatment discontinued before discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Pharmacotherapy" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 87232-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
OC | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| section:sectionImplantedDevices |
OC | 0..1 | BackboneElement | Devices and implants during the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Medical devices and implants" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57080-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantResults |
OC | 0..1 | BackboneElement | Significant medical test results of the stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant medical test results" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
OC | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
OC | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| section:sectionSynthesis |
OC | 0..1 | BackboneElement | Clinical synthesis of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Synthesis" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67781-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionPlanOfCare |
OC | 0..1 | BackboneElement | Plan of care and recommendations after discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Plan of care" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| entry |
OC | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeMedications |
OC | 0..1 | BackboneElement | Medication intended after discharge Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital discharge medications" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 75311-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| entry |
OC | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionAllergies |
C | 0..1 | BackboneElement | Relevant allergies and intolerances Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Allergies and intolerances" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
C | 0..* | Reference(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
OC | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| section:sectionPatientHx |
OC | 0..1 | BackboneElement | Narrative patient health history (anamnesis) Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Patient health history" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionProblems |
OC | 0..1 | BackboneElement | Problems currently being monitored Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Problem list" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
OC | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
OC | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionImmunizations |
C | 0..1 | BackboneElement | Immunization status and vaccination history Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Immunizations" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| Slices for entry |
C | 0..* | Reference(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
OC | 0..* | Reference(Immunization: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeDetails |
OC | 0..1 | BackboneElement | Discharge status and disposition of the patient Constraints: cmp-1, cmp-2
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Discharge details" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| section:sectionAttachments |
C | 0..1 | BackboneElement | Library of attachments Constraints: cmp-1, cmp-2 | ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Attachments" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 77599-9 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| entry |
OC | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.section.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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()
|
| text-or-section | error | Composition | A Composition SHALL have either text, at least one section, or both. |
text.exists() or section.exists()
|
Differential View
This structure is derived from CompositionEuHdr
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
CompositionEuHdr | |||||||||||
| language |
O | 0..1 | code | Language of the resource content
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:information-recipient |
0..* | InformationRecipient | Composition: Information recipient | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
| identifier |
O | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
O | 1..1 | code | HDR status
| ||||||||
| type |
O | 1..1 | CodeableConcept | Kind of composition ("Hospital Discharge Report")
| ||||||||
| category |
O | 0..* | CodeableConcept | Categorization of Composition
| ||||||||
| subject |
O | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
O | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
O | 1..1 | dateTime | HDR date
| ||||||||
| author |
O | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
O | 1..1 | string | Hospital Discharge Report
| ||||||||
| attester |
O | 0..* | BackboneElement | Attests to accuracy of composition
| ||||||||
| mode |
O | 1..1 | code | The type of attestation
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
O | 0..1 | Reference(Organization) | Organization which maintains the composition
| ||||||||
| event |
||||||||||||
| period |
O | 0..1 | Period | The period covered by the documentation
| ||||||||
| section |
O | 1..* | BackboneElement | Sections composing the HDR
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| Slices for section |
Content/Rules for all slices | |||||||||||
| section:sectionAlert |
O | 0..1 | BackboneElement | Substantial alerts and warnings
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
O | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| section:sectionAdmissionEvaluation |
O | 0..1 | BackboneElement | Patient evaluation at hospital admission
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionVitalSigns |
0..1 | BackboneElement | Vital signs during the encounter and at discharge | |||||||||
| entry |
0..* | Reference(Observation: obligations | DocumentReference | Vital Signs Profile) | A reference to data that supports this section | |||||||||
| section:sectionPhysicalFindings |
O | 0..1 | BackboneElement | Objective findings from physical examination
| ||||||||
| entry |
O | 0..* | Reference(Observation: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionFunctionalStatus |
O | 0..1 | BackboneElement | Ability to perform activities of daily living
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
O | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
O | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| section:sectionHospitalCourse |
O | 1..1 | BackboneElement | Significant information about course of hospital stay
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionDiagnosticSummary |
O | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantProcedures |
O | 0..1 | BackboneElement | Significant procedures performed during the stay
| ||||||||
| entry |
O | 0..* | Reference(Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionMedicalDevices |
O | 0..1 | BackboneElement | Devices used or implanted before this encounter
| ||||||||
| entry |
O | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
O | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| section:sectionProceduresHx |
O | 0..1 | BackboneElement | Past procedures relevant to this encounter
| ||||||||
| entry |
O | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
O | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| section:sectionPharmacotherapy |
O | 0..1 | BackboneElement | Drug treatment discontinued before discharge
| ||||||||
| entry |
O | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
O | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| section:sectionImplantedDevices |
O | 0..1 | BackboneElement | Devices and implants during the hospital stay
| ||||||||
| entry |
O | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionSignificantResults |
O | 0..1 | BackboneElement | Significant medical test results of the stay
| ||||||||
| entry |
O | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
O | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
O | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| section:sectionSynthesis |
O | 0..1 | BackboneElement | Clinical synthesis of the hospital stay
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionPlanOfCare |
O | 0..1 | BackboneElement | Plan of care and recommendations after discharge
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeMedications |
O | 0..1 | BackboneElement | Medication intended after discharge
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| entry |
O | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionAllergies |
0..1 | BackboneElement | Relevant allergies and intolerances | |||||||||
| entry |
0..* | Reference(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance | |||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
O | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| section:sectionPatientHx |
O | 0..1 | BackboneElement | Narrative patient health history (anamnesis)
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionProblems |
O | 0..1 | BackboneElement | Problems currently being monitored
| ||||||||
| entry |
O | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient.
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
O | 0..* | Reference(Condition: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionImmunizations |
0..1 | BackboneElement | Immunization status and vaccination history | |||||||||
| entry |
0..* | Reference(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. | |||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
O | 0..* | Reference(Immunization: obligations) | A reference to data that supports this section
| ||||||||
| section:sectionDischargeDetails |
O | 0..1 | BackboneElement | Discharge status and disposition of the patient
| ||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Note(5.3.0) | Additional notes that apply to this resource or element.
| ||||||||
| text |
O | 0..1 | Narrative | Text summary of the section, for human interpretation
| ||||||||
| section:sectionAttachments |
0..1 | BackboneElement | Library of attachments | |||||||||
| entry |
O | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| Documentation for this format | ||||||||||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | CompositionEuHdr | Hospital Discharge Report composition Constraints: text-or-section | ||||||||
| 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 |
O | 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||
| contained |
0..* | Resource | Contained, inline Resources | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:basedOn |
0..* | (Complex) | Fulfills plan, proposal or order URL: http://hl7.org/fhir/StructureDefinition/event-basedOn | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.org/fhir/StructureDefinition/event-basedOn" | |||||||||
| value[x] |
1..1 | Reference(Resource | ServiceRequest) | Value of extension | |||||||||
| extension:version |
0..1 | string | Business version URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version Constraints: ext-1 | |||||||||
| extension:information-recipient |
0..* | (Complex) | Composition: Information recipient URL: http://hl7.eu/fhir/StructureDefinition/information-recipient | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||||||
| url |
1..1 | uri | "http://hl7.eu/fhir/StructureDefinition/information-recipient" | |||||||||
| value[x] |
0..1 | Reference(PractitionerRole: obligations | Practitioner: obligations | Device: obligations | Patient: obligations | RelatedPerson: obligations | Organization: obligations) | Value of extension | |||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| identifier |
OΣ | 0..1 | Identifier | HDR business identifier
| ||||||||
| status |
?!OΣ | 1..1 | code | HDR status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
| ||||||||
| type |
OΣ | 1..1 | CodeableConcept | 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 Slice: Unordered, Open by value:url | |||||||||
| coding |
Σ | 0..* | 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 Slice: Unordered, Open by value:url | |||||||||
| system |
Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: 34105-7 | ||||||||
| display |
Σ | 1..1 | string | Representation defined by the system | ||||||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||||||
| category |
OΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Example Document category: {"system":"http://loinc.org","code":"LP72467-1","display":"Discharge summary note"}
| ||||||||
| subject |
OΣ | 1..1 | Reference(Patient: obligations) | Who and/or what the composition is about
| ||||||||
| encounter |
OΣ | 1..1 | Reference(Encounter: obligations) | Context of the Composition
| ||||||||
| date |
OΣ | 1..1 | dateTime | HDR date
| ||||||||
| author |
OΣ | 1..* | Reference(Practitioner: obligations | PractitionerRole: obligations | Device: obligations | Organization: obligations) | Who and/or what authored the Hospital Discharge Report
| ||||||||
| title |
OΣ | 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 |
O | 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 |
O | 1..1 | code | The type of attestation Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
| ||||||||
| time |
O | 0..1 | dateTime | When the composition was attested.
| ||||||||
| party |
O | 0..1 | Reference(Practitioner: obligations | PractitionerRole: obligations | Organization: obligations) | Who attested the composition.
| ||||||||
| custodian |
OΣ | 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 |
OΣ | 0..1 | Period | The period covered by the documentation
| ||||||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||||||
| Slices for section |
OC | 1..* | BackboneElement | Sections composing the HDR Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
| ||||||||
| section:All Slices |
Content/Rules for all slices | |||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| 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 | 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 |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionAlert |
OC | 0..1 | BackboneElement | Substantial alerts and warnings Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Alerts" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 104605-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(Flag: obligations | DocumentReference) | EPS Alerts entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:flag |
OC | 0..* | Reference(Flag: obligations) | Alert information
| ||||||||
| 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:sectionAdmissionEvaluation |
OC | 0..1 | BackboneElement | Patient evaluation at hospital admission Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital admission evaluation" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67851-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionVitalSigns |
C | 0..1 | BackboneElement | Vital signs during the encounter and at discharge Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Vital signs" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Observation: obligations | DocumentReference | Vital Signs Profile) | 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:sectionPhysicalFindings |
OC | 0..1 | BackboneElement | Objective findings from physical examination Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Physical findings" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Observation: obligations | DocumentReference) | 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:sectionFunctionalStatus |
OC | 0..1 | BackboneElement | Ability to perform activities of daily living Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Functional status" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations | ClinicalImpression | Observation: obligations | DocumentReference | QuestionnaireResponse) | Disabilities and Functional assessments Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:condition |
OC | 0..* | Reference(Condition: obligations) | Functional status condition entry
| ||||||||
| entry:observation |
OC | 0..* | Reference(Observation: obligations) | Functional status observation entry
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionHospitalCourse |
OC | 1..1 | BackboneElement | Significant information about course of hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital course" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8648-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionDiagnosticSummary |
OC | 0..1 | BackboneElement | Problems and diagnoses of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Diagnostic summary" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11535-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations) | 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:sectionSignificantProcedures |
OC | 0..1 | BackboneElement | Significant procedures performed during the stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 10185-7 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Procedure: obligations) | 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:sectionMedicalDevices |
OC | 0..1 | BackboneElement | Devices used or implanted before this encounter Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of medical device use" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations | DocumentReference) | Medical Device entry Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:deviceStatement |
OC | 0..* | Reference(DeviceUseStatement: obligations) | Patient history of medical device use
| ||||||||
| 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:sectionProceduresHx |
OC | 0..1 | BackboneElement | Past procedures relevant to this encounter Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "History of procedures" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Procedure: obligations | DocumentReference) | Slice on procedure Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:procedure |
OC | 0..* | Reference(Procedure: obligations) | Patient past procedures pertinent to the scope of this document.
| ||||||||
| 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:sectionPharmacotherapy |
OC | 0..1 | BackboneElement | Drug treatment discontinued before discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Pharmacotherapy" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 87232-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(MedicationStatement: obligations | MedicationRequest: obligations | MedicationDispense: obligations | MedicationAdministration: obligations) | Medication Use slice Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:medicationStatement |
OC | 0..* | Reference(MedicationStatement: obligations) | Medication Use
| ||||||||
| 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:sectionImplantedDevices |
OC | 0..1 | BackboneElement | Devices and implants during the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Medical devices and implants" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57080-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DeviceUseStatement: obligations | Procedure: obligations) | 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:sectionSignificantResults |
OC | 0..1 | BackboneElement | Significant medical test results of the stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Significant medical test results" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Observation: obligations | DiagnosticReport | DocumentReference) | Significant medical test results Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:results-medicalTestResult |
OC | 0..* | Reference(Observation: obligations) | Medical test results
| ||||||||
| entry:results-diagnosticReport |
OC | 0..* | Reference(DiagnosticReport (EU core)) | DiagnosticReport
| ||||||||
| 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:sectionSynthesis |
OC | 0..1 | BackboneElement | Clinical synthesis of the hospital stay Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Synthesis" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 67781-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionPlanOfCare |
OC | 0..1 | BackboneElement | Plan of care and recommendations after discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Plan of care" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(Care Plan: obligations | DocumentReference) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionDischargeMedications |
OC | 0..1 | BackboneElement | Medication intended after discharge Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Hospital discharge medications" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 75311-1 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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 |
OC | 0..* | Reference(MedicationRequest: obligations | MedicationDispense: obligations | MedicationStatement: obligations) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| section:sectionAllergies |
C | 0..1 | BackboneElement | Relevant allergies and intolerances Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Allergies and intolerances" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Allergy Intolerance: obligations | DocumentReference) | allergyOrIntolerance Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:allergyOrIntolerance |
OC | 0..* | Reference(Allergy Intolerance: obligations) | Relevant allergies or intolerances for that patient.
| ||||||||
| 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:sectionPatientHx |
OC | 0..1 | BackboneElement | Narrative patient health history (anamnesis) Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Patient health history" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionProblems |
OC | 0..1 | BackboneElement | Problems currently being monitored Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Problem list" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(Condition: obligations | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by type:resolve()
| ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:problem |
OC | 0..* | Reference(Condition: obligations) | 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:sectionImmunizations |
C | 0..1 | BackboneElement | Immunization status and vaccination history Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Immunizations" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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(Immunization: obligations | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by type:resolve() | ||||||||
| Slices for entry |
Content/Rules for all slices | |||||||||||
| entry:immunization |
OC | 0..* | Reference(Immunization: obligations) | 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:sectionDischargeDetails |
OC | 0..1 | BackboneElement | Discharge status and disposition of the patient Constraints: cmp-1, cmp-2
| ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
O | 0..* | Annotation | Additional notes that apply to this resource or element. URL: http://hl7.org/fhir/StructureDefinition/note
| ||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Discharge details" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 8650-4 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
OC | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
| ||||||||
| 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:sectionAttachments |
C | 0..1 | BackboneElement | Library of attachments Constraints: cmp-1, cmp-2 | ||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||
| Slices for extension |
Content/Rules for all slices | |||||||||||
| extension:section-note |
0..* | Annotation | Additional notes that apply to the section (but not to specific resource). URL: http://hl7.org/fhir/StructureDefinition/note | |||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
| title |
1..1 | string | Label of section, e.g. "Attachments" for ToC | |||||||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 77599-9 | |||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||||||
| 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 |
OC | 0..* | Reference(DocumentReference | Binary) | A reference to data that supports this section
| ||||||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std. |
| Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std. |
| Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std. |
| Composition.attester.mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std. |
| Composition.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.3 |
| Composition.section.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAlert.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAdmissionEvaluation.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionVitalSigns.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPhysicalFindings.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionFunctionalStatus.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionHospitalCourse.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDiagnosticSummary.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantProcedures.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionMedicalDevices.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProceduresHx.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPharmacotherapy.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImplantedDevices.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSignificantResults.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionSynthesis.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPlanOfCare.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeMedications.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAllergies.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionPatientHx.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionProblems.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionImmunizations.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionDischargeDetails.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.mode | Base | required | ListMode | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std. |
| Composition.section:sectionAttachments.emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| cmp-1 | error | Composition.section, Composition.section:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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:sectionAlert, Composition.section:sectionAdmissionEvaluation, Composition.section:sectionVitalSigns, Composition.section:sectionPhysicalFindings, Composition.section:sectionFunctionalStatus, Composition.section:sectionHospitalCourse, Composition.section:sectionDiagnosticSummary, Composition.section:sectionSignificantProcedures, Composition.section:sectionMedicalDevices, Composition.section:sectionProceduresHx, Composition.section:sectionPharmacotherapy, Composition.section:sectionImplantedDevices, Composition.section:sectionSignificantResults, Composition.section:sectionSynthesis, Composition.section:sectionPlanOfCare, Composition.section:sectionDischargeMedications, Composition.section:sectionAllergies, Composition.section:sectionPatientHx, Composition.section:sectionProblems, Composition.section:sectionImmunizations, Composition.section:sectionDischargeDetails, 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()
|
| text-or-section | error | Composition | A Composition SHALL have either text, at least one section, or both. |
text.exists() or section.exists()
|
This structure is derived from CompositionEuHdr
Summary
Structures
This structure refers to these other structures:
Maturity: 0
Other representations of profile: CSV, Excel, Schematron
Contents:
In order to support the different maturity levels foreseen for the European EHR eXchange format (structured, text-only, unstructured), this version of the guide does not impose the mandatory presence of entries in the HDR sections.
However, the presence of entries in the HDR sections is generally recommended to ensure a more structured and interoperable document.
This recommendation is expressed in this guide through specific obligations which guide implementers toward achieving a higher level of data quality and interoperability.
To address the Hospital Discharge Report Structure Challenge , we have opted for a flexible approach rather than imposing a rigid format.
The "flat structure" documented in the guide should be understood as a sort of "section library" that can be reused in both flat and nested structures. This approach allows implementers to organize the report according to local or institutional needs while maintaining a standardized content model.
In practice:
By offering this level of flexibility, the implementation guide supports diverse healthcare environments while promoting consistency in content and interoperability.
The timing of the condition may be used to determine whether it was already
present at the time of admission or developed during the hospital stay.
In particular, Condition.onset[x] may be compared with the
admission date and time, or with the start of the referenced encounter.
Condition.category may also provide contextual information about the role of the condition; however, a specific category or coding convention should be defined for this purpose.
IG © 2024+ HL7 Europe. Package hl7.fhir.eu.hdr#1.0.0-ci based on FHIR 4.0.1. Generated 2026-08-08
