Mobile Antepartum Summary
1.0.0-comment - ballot
This page is part of the Mobile Antepartum Summary (v1.0.0-comment: Publication Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: https://profiles.ihe.net/PCC/mAPS/StructureDefinition/IHE.PCC.APS.Composition | Version: 1.0.0-comment | |||
Active as of 2024-06-04 | Computable Name: IHE_APS_Composition |
Antepartum Summary is a content profile that defines the structure for the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is represented in part by Estimated Due Dates and a Visit Summary Flowsheet, in which the aggregated data from the ambulatory office visits is recorded, as well as allergies, advance directives, care plans, and selected histories are provided. The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
identifier | S | 0..1 | Identifier | Version-independent identifier for the Composition |
status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
coding:asummary | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |
Slices for category | S | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this |
category:pstat | 1..1 | CodeableConcept | Categorization of Composition Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 90767-5 | |
subject | S | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about |
encounter | S | 0..1 | Reference(Encounter) | Context of the Composition |
date | S | 1..1 | dateTime | Composition editing time |
author | S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | S | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
mode | S | 1..1 | code | personal | professional | legal | official |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the composition |
event | S | 0..* | BackboneElement | The clinical service(s) being documented |
Slices for code | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this | |
code:obs | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |
Slices for section | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:All Slices | Content/Rules for all slices | |||
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | 1..1 | BackboneElement | Medication Summary Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAllergies | 1..1 | BackboneElement | Allergies and Intolerances Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | 1..1 | BackboneElement | Problems Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPastIllnessHx | 1..1 | BackboneElement | History of Past Illness Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionSocialHistory | 0..1 | BackboneElement | Social History Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProceduresHx | 1..1 | BackboneElement | History of Procedures Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
entry | S | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPregnancyHx | 1..1 | BackboneElement | History of Pregnancy Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPlanOfCare | 0..1 | BackboneElement | Plan of Care Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
entry | S | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionImmunizations | 1..1 | BackboneElement | Immunization Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
entry | S | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionResults | 0..1 | BackboneElement | Results Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
entry | S | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAdvanceDirectives | 0..1 | BackboneElement | Advance Directives Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
entry | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionVitalSigns | 0..1 | BackboneElement | Vital Signs Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
entry | 0..* | Reference(Observation | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:ChiefComplaint | 0..1 | BackboneElement | Cheif Complaint Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
section:FamilyMedicalHistory | 0..1 | BackboneElement | Family Medical History | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
entry | 0..* | Reference(Observation) | A reference to data that supports this section | |
section:ReviewOfSystems | 0..1 | BackboneElement | Review of Systems | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
entry | 0..* | Reference(Observation | Menstrual Status) | A reference to data that supports this section | |
section:HistoryOfInfection | 0..1 | BackboneElement | History of Infection | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |
entry | 0..* | Reference(Condition) | A reference to data that supports this section | |
section:PhysicalExams | 0..1 | BackboneElement | Physical Exams | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | 0..* | Reference(Observation) | A reference to data that supports this section | |
section:AntepartumEducation | 0..1 | BackboneElement | AntepartumEducation | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |
entry | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | DocumentReference) | A reference to data that supports this section | |
section:Payors | 0..1 | BackboneElement | Payors | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
entry | 0..* | Reference(Coverage) | A reference to data that supports this section | |
section:AntepartumVisitSummaryFlowsheet | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |
entry | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition |
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
coding:asummary | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:pstat | Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 90767-5 | |
subject | SΣ | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about |
encounter | SΣ | 0..1 | Reference(Encounter) | Context of the Composition |
date | SΣ | 1..1 | dateTime | Composition editing time |
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | SΣ | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
Slices for code | Σ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
code:obs | Σ | 1..1 | 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. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |
Slices for section | C | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | C | 1..1 | BackboneElement | Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionAllergies | C | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionProblems | C | 1..1 | BackboneElement | Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPastIllnessHx | C | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionSocialHistory | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionProceduresHx | C | 1..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
entry | SC | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPregnancyHx | C | 1..1 | BackboneElement | History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPlanOfCare | C | 0..1 | BackboneElement | Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
entry | SC | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionImmunizations | C | 1..1 | BackboneElement | Immunization Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
entry | SC | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionResults | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
entry | SC | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
entry | C | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionVitalSigns | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
entry | C | 0..* | Reference(Observation | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:ChiefComplaint | C | 0..1 | BackboneElement | Cheif Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
section:FamilyMedicalHistory | C | 0..1 | BackboneElement | Family Medical History cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
entry | C | 0..* | Reference(Observation) | A reference to data that supports this section |
section:ReviewOfSystems | C | 0..1 | BackboneElement | Review of Systems cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
entry | C | 0..* | Reference(Observation | Menstrual Status) | A reference to data that supports this section |
section:HistoryOfInfection | C | 0..1 | BackboneElement | History of Infection cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section |
section:PhysicalExams | C | 0..1 | BackboneElement | Physical Exams cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | C | 0..* | Reference(Observation) | A reference to data that supports this section |
section:AntepartumEducation | C | 0..1 | BackboneElement | AntepartumEducation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |
entry | C | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | DocumentReference) | A reference to data that supports this section |
section:Payors | C | 0..1 | BackboneElement | Payors cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section |
section:AntepartumVisitSummaryFlowsheet | C | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |
entry | C | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 90767-5http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.event.code:obs | example | Pattern: OBShttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPlanOfCare.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:ChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:FamilyMedicalHistory.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:ReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:HistoryOfInfection.code | example | Pattern: LOINC Code 56838-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:PhysicalExams.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:AntepartumEducation.code | example | Pattern: LOINC Code 34895-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:Payors.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:AntepartumVisitSummaryFlowsheet.code | example | Pattern: LOINC Code 57059-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
coding:asummary | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:pstat | Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 90767-5 | |||||
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 | |||||
subject | SΣ | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
date | SΣ | 1..1 | dateTime | Composition editing time | ||||
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary | ||||
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 | S | 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 | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
time | S | 0..1 | dateTime | When the composition was attested | ||||
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
custodian | SΣ | 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 | SΣ | 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 | ||||
Slices for code | Σ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
code:obs | Σ | 1..1 | 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. 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://terminology.hl7.org/CodeSystem/v3-ActCode | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |||||
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 | |||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionMedications | C | 1..1 | BackboneElement | Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary | ||||
emptyReason | SC | 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 | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. | ||||
emptyReason | SC | 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 | C | 1..1 | BackboneElement | Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. | ||||
emptyReason | SC | 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:sectionPastIllnessHx | C | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. | ||||
emptyReason | SC | 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:sectionSocialHistory | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) | ||||
emptyReason | SC | 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 | C | 1..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. | ||||
emptyReason | SC | 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:sectionPregnancyHx | C | 1..1 | BackboneElement | History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. | ||||
emptyReason | SC | 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 | C | 0..1 | BackboneElement | Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans | ||||
emptyReason | SC | 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 | 1..1 | BackboneElement | Immunization Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. | ||||
emptyReason | SC | 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:sectionResults | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. | ||||
emptyReason | SC | 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:sectionAdvanceDirectives | C | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. | ||||
emptyReason | SC | 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 Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. | ||||
emptyReason | SC | 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:ChiefComplaint | C | 0..1 | BackboneElement | Cheif Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(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:FamilyMedicalHistory | C | 0..1 | BackboneElement | Family Medical History cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation) | 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:ReviewOfSystems | C | 0..1 | BackboneElement | Review of Systems cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation | Menstrual Status) | 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:HistoryOfInfection | C | 0..1 | BackboneElement | History of Infection cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Condition) | 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:PhysicalExams | C | 0..1 | BackboneElement | Physical Exams cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation) | 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:AntepartumEducation | C | 0..1 | BackboneElement | AntepartumEducation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | 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:Payors | C | 0..1 | BackboneElement | Payors cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Coverage) | 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:AntepartumVisitSummaryFlowsheet | C | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.category:pstat | example | Pattern: LOINC Code 90767-5http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.event.code:obs | example | Pattern: OBShttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProblems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:ChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:ChiefComplaint.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:ChiefComplaint.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:ChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.code | example | Pattern: LOINC Code 56838-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:PhysicalExams.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:PhysicalExams.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:PhysicalExams.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:PhysicalExams.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:AntepartumEducation.code | example | Pattern: LOINC Code 34895-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:AntepartumEducation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:AntepartumEducation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:AntepartumEducation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:Payors.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:Payors.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:Payors.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:Payors.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.code | example | Pattern: LOINC Code 57059-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
This structure is derived from Composition
Summary
Mandatory: 15 elements(2 nested mandatory elements)
Must-Support: 41 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
identifier | S | 0..1 | Identifier | Version-independent identifier for the Composition |
status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
coding:asummary | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |
Slices for category | S | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this |
category:pstat | 1..1 | CodeableConcept | Categorization of Composition Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 90767-5 | |
subject | S | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about |
encounter | S | 0..1 | Reference(Encounter) | Context of the Composition |
date | S | 1..1 | dateTime | Composition editing time |
author | S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | S | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
mode | S | 1..1 | code | personal | professional | legal | official |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the composition |
event | S | 0..* | BackboneElement | The clinical service(s) being documented |
Slices for code | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this | |
code:obs | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |
Slices for section | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:All Slices | Content/Rules for all slices | |||
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | 1..1 | BackboneElement | Medication Summary Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAllergies | 1..1 | BackboneElement | Allergies and Intolerances Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | 1..1 | BackboneElement | Problems Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPastIllnessHx | 1..1 | BackboneElement | History of Past Illness Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionSocialHistory | 0..1 | BackboneElement | Social History Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProceduresHx | 1..1 | BackboneElement | History of Procedures Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
entry | S | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPregnancyHx | 1..1 | BackboneElement | History of Pregnancy Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPlanOfCare | 0..1 | BackboneElement | Plan of Care Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
entry | S | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionImmunizations | 1..1 | BackboneElement | Immunization Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
entry | S | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionResults | 0..1 | BackboneElement | Results Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
entry | S | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAdvanceDirectives | 0..1 | BackboneElement | Advance Directives Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
entry | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionVitalSigns | 0..1 | BackboneElement | Vital Signs Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
entry | 0..* | Reference(Observation | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:ChiefComplaint | 0..1 | BackboneElement | Cheif Complaint Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
section:FamilyMedicalHistory | 0..1 | BackboneElement | Family Medical History | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
entry | 0..* | Reference(Observation) | A reference to data that supports this section | |
section:ReviewOfSystems | 0..1 | BackboneElement | Review of Systems | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
entry | 0..* | Reference(Observation | Menstrual Status) | A reference to data that supports this section | |
section:HistoryOfInfection | 0..1 | BackboneElement | History of Infection | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |
entry | 0..* | Reference(Condition) | A reference to data that supports this section | |
section:PhysicalExams | 0..1 | BackboneElement | Physical Exams | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | 0..* | Reference(Observation) | A reference to data that supports this section | |
section:AntepartumEducation | 0..1 | BackboneElement | AntepartumEducation | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |
entry | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | DocumentReference) | A reference to data that supports this section | |
section:Payors | 0..1 | BackboneElement | Payors | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
entry | 0..* | Reference(Coverage) | A reference to data that supports this section | |
section:AntepartumVisitSummaryFlowsheet | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |
entry | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition |
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
coding:asummary | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:pstat | Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 90767-5 | |
subject | SΣ | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about |
encounter | SΣ | 0..1 | Reference(Encounter) | Context of the Composition |
date | SΣ | 1..1 | dateTime | Composition editing time |
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | SΣ | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
event | SΣ | 0..* | BackboneElement | The clinical service(s) being documented |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
Slices for code | Σ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
code:obs | Σ | 1..1 | 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. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |
Slices for section | C | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | C | 1..1 | BackboneElement | Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionAllergies | C | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionProblems | C | 1..1 | BackboneElement | Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPastIllnessHx | C | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionSocialHistory | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionProceduresHx | C | 1..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
entry | SC | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPregnancyHx | C | 1..1 | BackboneElement | History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionPlanOfCare | C | 0..1 | BackboneElement | Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
entry | SC | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionImmunizations | C | 1..1 | BackboneElement | Immunization Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
entry | SC | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionResults | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
entry | SC | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
entry | C | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:sectionVitalSigns | C | 0..1 | BackboneElement | Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
entry | C | 0..* | Reference(Observation | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. |
emptyReason | SC | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
section:ChiefComplaint | C | 0..1 | BackboneElement | Cheif Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
section:FamilyMedicalHistory | C | 0..1 | BackboneElement | Family Medical History cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
entry | C | 0..* | Reference(Observation) | A reference to data that supports this section |
section:ReviewOfSystems | C | 0..1 | BackboneElement | Review of Systems cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
entry | C | 0..* | Reference(Observation | Menstrual Status) | A reference to data that supports this section |
section:HistoryOfInfection | C | 0..1 | BackboneElement | History of Infection cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |
entry | C | 0..* | Reference(Condition) | A reference to data that supports this section |
section:PhysicalExams | C | 0..1 | BackboneElement | Physical Exams cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
entry | C | 0..* | Reference(Observation) | A reference to data that supports this section |
section:AntepartumEducation | C | 0..1 | BackboneElement | AntepartumEducation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |
entry | C | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | DocumentReference) | A reference to data that supports this section |
section:Payors | C | 0..1 | BackboneElement | Payors cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |
entry | C | 0..* | Reference(Coverage) | A reference to data that supports this section |
section:AntepartumVisitSummaryFlowsheet | C | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |
entry | C | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.category:pstat | example | Pattern: LOINC Code 90767-5http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.event.code:obs | example | Pattern: OBShttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPregnancyHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionPlanOfCare.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionAdvanceDirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | |
Composition.section:ChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:FamilyMedicalHistory.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:ReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:HistoryOfInfection.code | example | Pattern: LOINC Code 56838-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:PhysicalExams.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:AntepartumEducation.code | example | Pattern: LOINC Code 34895-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:Payors.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:AntepartumVisitSummaryFlowsheet.code | example | Pattern: LOINC Code 57059-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
coding:asummary | Σ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
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: 57055-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:pstat | Σ | 1..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 90767-5 | |||||
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 | |||||
subject | SΣ | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
date | SΣ | 1..1 | dateTime | Composition editing time | ||||
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | SΣ | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary | ||||
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 | S | 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 | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
time | S | 0..1 | dateTime | When the composition was attested | ||||
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
custodian | SΣ | 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 | SΣ | 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 | ||||
Slices for code | Σ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
code:obs | Σ | 1..1 | 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. 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://terminology.hl7.org/CodeSystem/v3-ActCode | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |||||
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 | |||||
period | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | C | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
section:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
section:sectionMedications | C | 1..1 | BackboneElement | Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary | ||||
emptyReason | SC | 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 | 1..1 | BackboneElement | Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. | ||||
emptyReason | SC | 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 | C | 1..1 | BackboneElement | Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. | ||||
emptyReason | SC | 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:sectionPastIllnessHx | C | 1..1 | BackboneElement | History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. | ||||
emptyReason | SC | 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:sectionSocialHistory | C | 0..1 | BackboneElement | Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) | ||||
emptyReason | SC | 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 | C | 1..1 | BackboneElement | History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. | ||||
emptyReason | SC | 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:sectionPregnancyHx | C | 1..1 | BackboneElement | History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. | ||||
emptyReason | SC | 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 | C | 0..1 | BackboneElement | Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans | ||||
emptyReason | SC | 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 | 1..1 | BackboneElement | Immunization Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | SC | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. | ||||
emptyReason | SC | 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:sectionResults | C | 0..1 | BackboneElement | Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | SC | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. | ||||
emptyReason | SC | 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:sectionAdvanceDirectives | C | 0..1 | BackboneElement | Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Consent | DocumentReference) | the patient's advance directive. | ||||
emptyReason | SC | 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 Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 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 | ||||
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 | DocumentReference | Vital Signs Profile) | Notable vital signs or physical findings. | ||||
emptyReason | SC | 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:ChiefComplaint | C | 0..1 | BackboneElement | Cheif Complaint Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(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:FamilyMedicalHistory | C | 0..1 | BackboneElement | Family Medical History cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation) | 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:ReviewOfSystems | C | 0..1 | BackboneElement | Review of Systems cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation | Menstrual Status) | 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:HistoryOfInfection | C | 0..1 | BackboneElement | History of Infection cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 56838-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Condition) | 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:PhysicalExams | C | 0..1 | BackboneElement | Physical Exams cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation) | 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:AntepartumEducation | C | 0..1 | BackboneElement | AntepartumEducation cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34895-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Procedure | Pregnancy Education Observation | Observation | 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:Payors | C | 0..1 | BackboneElement | Payors cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48768-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Coverage) | 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:AntepartumVisitSummaryFlowsheet | C | 0..1 | BackboneElement | Antepartum Visit Summary Flowsheet cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57059-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Observation | Antepartum Visit Summary Flowsheet Battery) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.category:pstat | example | Pattern: LOINC Code 90767-5http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.event.code:obs | example | Pattern: OBShttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionMedications.code | example | Pattern: LOINC Code 10160-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionMedications.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionMedications.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionMedications.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAllergies.code | example | Pattern: LOINC Code 48765-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAllergies.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAllergies.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAllergies.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionProblems.code | example | Pattern: LOINC Code 11450-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProblems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProblems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProblems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.code | example | Pattern: LOINC Code 11348-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPastIllnessHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.code | example | Pattern: LOINC Code 29762-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionSocialHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.code | example | Pattern: LOINC Code 47519-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionProceduresHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.code | example | Pattern: LOINC Code 10162-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPregnancyHx.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.code | example | Pattern: LOINC Code 18776-5http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionPlanOfCare.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionImmunizations.code | example | Pattern: LOINC Code 11369-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionImmunizations.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionImmunizations.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionImmunizations.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionResults.code | example | Pattern: LOINC Code 30954-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionResults.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionResults.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionResults.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.code | example | Pattern: LOINC Code 42348-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionAdvanceDirectives.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.code | example | Pattern: LOINC Code 8716-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:sectionVitalSigns.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:ChiefComplaint.code | example | Pattern: LOINC Code 10154-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:ChiefComplaint.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:ChiefComplaint.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:ChiefComplaint.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.code | example | Pattern: LOINC Code 10157-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:FamilyMedicalHistory.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.code | example | Pattern: LOINC Code 10187-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:ReviewOfSystems.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.code | example | Pattern: LOINC Code 56838-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:HistoryOfInfection.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:PhysicalExams.code | example | Pattern: LOINC Code 29545-1http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:PhysicalExams.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:PhysicalExams.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:PhysicalExams.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:AntepartumEducation.code | example | Pattern: LOINC Code 34895-3http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:AntepartumEducation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:AntepartumEducation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:AntepartumEducation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:Payors.code | example | Pattern: LOINC Code 48768-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:Payors.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:Payors.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:Payors.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.code | example | Pattern: LOINC Code 57059-8http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section:AntepartumVisitSummaryFlowsheet.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
This structure is derived from Composition
Summary
Mandatory: 15 elements(2 nested mandatory elements)
Must-Support: 41 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron