Mobile Antepartum Summary
1.0.0-comment - ballot International flag

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. For a full list of available versions, see the Directory of published versions

Resource Profile: IHE_APS_Composition - Detailed Descriptions

Active as of 2024-06-04

Definitions for the IHE.PCC.APS.Composition resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Composition
2. Composition.text
Must Supporttrue
4. Composition.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Must Supporttrue
6. Composition.status
Must Supporttrue
8. Composition.type
Must Supporttrue
10. Composition.type.coding
Control1..?
SlicingThis element introduces a set of slices on Composition.type.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 12. Composition.type.coding:asummary
    Slice Nameasummary
    Control1..1
    Pattern Value{
      "system" : "http://loinc.org",
      "code" : "57055-6"
    }
    14. Composition.category
    Control1..?
    Must Supporttrue
    SlicingThis element introduces a set of slices on Composition.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • pattern @ $this
    • 16. Composition.category:pstat
      Slice Namepstat
      Control1..1
      Pattern Value{
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "90767-5"
        }]
      }
      18. Composition.subject
      Control1..?
      TypeReference(PDQm Patient Profile)
      Must Supporttrue
      20. Composition.encounter
      Must Supporttrue
      22. Composition.date
      Must Supporttrue
      24. Composition.author
      Must Supporttrue
      26. Composition.title
      Must Supporttrue
      Pattern ValueAntepartum Summary
      28. Composition.attester
      Must Supporttrue
      30. Composition.attester.mode
      Must Supporttrue
      32. Composition.attester.time
      Must Supporttrue
      34. Composition.attester.party
      Must Supporttrue
      36. Composition.custodian
      Must Supporttrue
      38. Composition.event
      Must Supporttrue
      40. Composition.event.code
      Control1..?
      SlicingThis element introduces a set of slices on Composition.event.code. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • pattern @ $this
      • 42. Composition.event.code:obs
        Slice Nameobs
        Control1..1
        Pattern Value{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code" : "OBS"
          }]
        }
        44. Composition.section
        Control7..?
        SlicingThis element introduces a set of slices on Composition.section. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • pattern @ code
        • 46. Composition.section.title
          Control1..?
          Must Supporttrue
          48. Composition.section.code
          Control1..?
          TypeCodeableConcept(Codeable Concept (IPS))
          Must Supporttrue
          50. Composition.section.text
          Control1..?
          Must Supporttrue
          52. Composition.section:sectionMedications
          Slice NamesectionMedications
          Definition

          TBD

          ShortMedication Summary Section
          Control1..1
          54. Composition.section:sectionMedications.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "10160-0"
            }]
          }
          56. Composition.section:sectionMedications.entry
          ShortMedications relevant for the scope of the patient summary
          TypeReference(MedicationStatement, MedicationRequest, MedicationAdministration, MedicationDispense, DocumentReference, Medication Statement (IPS), Medication Request (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          58. Composition.section:sectionMedications.emptyReason
          Must Supporttrue
          60. Composition.section:sectionAllergies
          Slice NamesectionAllergies
          Definition

          TBD

          ShortAllergies and Intolerances Section
          Control1..1
          62. Composition.section:sectionAllergies.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "48765-2"
            }]
          }
          64. Composition.section:sectionAllergies.entry
          ShortRelevant allergies or intolerances (conditions) for that patient.
          TypeReference(AllergyIntolerance, DocumentReference, Allergy Intolerance (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          66. Composition.section:sectionAllergies.emptyReason
          Must Supporttrue
          68. Composition.section:sectionProblems
          Slice NamesectionProblems
          Definition

          TBD

          ShortProblems Section
          Control1..1
          70. Composition.section:sectionProblems.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "11450-4"
            }]
          }
          72. Composition.section:sectionProblems.entry
          ShortClinical problems or conditions currently being monitored for the patient.
          TypeReference(Condition, DocumentReference, Condition (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          74. Composition.section:sectionProblems.emptyReason
          Must Supporttrue
          76. Composition.section:sectionPastIllnessHx
          Slice NamesectionPastIllnessHx
          Definition

          TBD

          ShortHistory of Past Illness Section
          Control1..1
          78. Composition.section:sectionPastIllnessHx.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "11348-0"
            }]
          }
          80. Composition.section:sectionPastIllnessHx.entry
          ShortConditions the patient suffered in the past.
          TypeReference(Condition, DocumentReference, Condition (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          82. Composition.section:sectionPastIllnessHx.emptyReason
          Must Supporttrue
          84. Composition.section:sectionSocialHistory
          Slice NamesectionSocialHistory
          Definition

          TBD

          ShortSocial History Section
          Control0..1
          86. Composition.section:sectionSocialHistory.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "29762-2"
            }]
          }
          88. Composition.section:sectionSocialHistory.entry
          ShortHealth related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.)
          TypeReference(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)
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          90. Composition.section:sectionSocialHistory.emptyReason
          Must Supporttrue
          92. Composition.section:sectionProceduresHx
          Slice NamesectionProceduresHx
          Definition

          TBD

          ShortHistory of Procedures Section
          Control1..1
          94. Composition.section:sectionProceduresHx.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "47519-4"
            }]
          }
          96. Composition.section:sectionProceduresHx.entry
          ShortPatient past procedures pertinent to the scope of this document.
          TypeReference(Procedure, DocumentReference, Procedure (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          98. Composition.section:sectionProceduresHx.emptyReason
          Must Supporttrue
          100. Composition.section:sectionPregnancyHx
          Slice NamesectionPregnancyHx
          Definition

          TBD

          ShortHistory of Pregnancy Section
          Control1..1
          102. Composition.section:sectionPregnancyHx.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "10162-6"
            }]
          }
          104. Composition.section:sectionPregnancyHx.entry
          ShortCurrent pregnancy status and, optionally, information about the outcome of earlier pregnancies.
          TypeReference(Observation, DocumentReference, Observation - Pregnancy: status, Observation - Pregnancy: outcome, Multiple Pregnancy, Gestational Age, Date Of Last Menstral Period, Pregnancy History Observations)
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          106. Composition.section:sectionPregnancyHx.emptyReason
          Must Supporttrue
          108. Composition.section:sectionPlanOfCare
          Slice NamesectionPlanOfCare
          Definition

          TBD

          ShortPlan of Care Section
          Control0..1
          110. Composition.section:sectionPlanOfCare.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "18776-5"
            }]
          }
          112. Composition.section:sectionPlanOfCare.entry
          Shortentry used to represent structured care plans
          TypeReference(CarePlan, DocumentReference)
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          114. Composition.section:sectionPlanOfCare.emptyReason
          Must Supporttrue
          116. Composition.section:sectionImmunizations
          Slice NamesectionImmunizations
          Definition

          TBD

          ShortImmunization Section
          Control1..1
          118. Composition.section:sectionImmunizations.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "11369-6"
            }]
          }
          120. Composition.section:sectionImmunizations.entry
          ShortPatient's immunization status and pertinent history.
          TypeReference(Immunization, DocumentReference, Immunization (IPS))
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          122. Composition.section:sectionImmunizations.emptyReason
          Must Supporttrue
          124. Composition.section:sectionResults
          Slice NamesectionResults
          Definition

          TBD

          ShortResults Section
          Control0..1
          126. Composition.section:sectionResults.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "30954-2"
            }]
          }
          128. Composition.section:sectionResults.entry
          ShortRelevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
          TypeReference(Observation, Observation Results (IPS), DiagnosticReport, DocumentReference, Antepartum Labs, Antepartum Genetic Screenings)
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          130. Composition.section:sectionResults.emptyReason
          Must Supporttrue
          132. Composition.section:sectionAdvanceDirectives
          Slice NamesectionAdvanceDirectives
          Definition

          TBD

          ShortAdvance Directives Section
          Control0..1
          134. Composition.section:sectionAdvanceDirectives.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "42348-3"
            }]
          }
          136. Composition.section:sectionAdvanceDirectives.entry
          Shortthe patient's advance directive.
          TypeReference(Consent, DocumentReference)
          138. Composition.section:sectionAdvanceDirectives.emptyReason
          Must Supporttrue
          140. Composition.section:sectionVitalSigns
          Slice NamesectionVitalSigns
          Definition

          TBD

          ShortVital Signs Section
          Control0..1
          142. Composition.section:sectionVitalSigns.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "8716-3"
            }]
          }
          144. Composition.section:sectionVitalSigns.entry
          ShortNotable vital signs or physical findings.
          TypeReference(Observation, DocumentReference, Vital Signs Profile)
          146. Composition.section:sectionVitalSigns.emptyReason
          Must Supporttrue
          148. Composition.section:ChiefComplaint
          Slice NameChiefComplaint
          Definition

          Chief complaint records the patient's primary complaint (the patient's own description).

          ShortCheif Complaint Section
          Control0..1
          150. Composition.section:ChiefComplaint.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "10154-3"
            }]
          }
          152. Composition.section:FamilyMedicalHistory
          Slice NameFamilyMedicalHistory
          Definition

          The family history section shall include entries for family history

          ShortFamily Medical History
          Control0..1
          154. Composition.section:FamilyMedicalHistory.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "10157-6"
            }]
          }
          156. Composition.section:FamilyMedicalHistory.entry
          TypeReference(Observation)
          158. Composition.section:ReviewOfSystems
          Slice NameReviewOfSystems
          Definition

          The review of systems section shall contain a narrative description of the responses the patient gave to a set of routine questions on the functions of each anatomic body system.

          ShortReview of Systems
          Control0..1
          160. Composition.section:ReviewOfSystems.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "10187-3"
            }]
          }
          162. Composition.section:ReviewOfSystems.entry
          TypeReference(Observation, Menstrual Status)
          164. Composition.section:HistoryOfInfection
          Slice NameHistoryOfInfection
          Definition

          The History of Infection section shall contain a narrative description of any infections the patient may have contracted prior to the patient's current condition.

          ShortHistory of Infection
          Control0..1
          166. Composition.section:HistoryOfInfection.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "56838-6"
            }]
          }
          168. Composition.section:HistoryOfInfection.entry
          TypeReference(Condition)
          170. Composition.section:PhysicalExams
          Slice NamePhysicalExams
          Definition

          The coded Detailed Physical Examination section shall contain only the required and optional subsections performed.

          ShortPhysical Exams
          Control0..1
          172. Composition.section:PhysicalExams.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "29545-1"
            }]
          }
          174. Composition.section:PhysicalExams.entry
          TypeReference(Observation)
          176. Composition.section:AntepartumEducation
          Slice NameAntepartumEducation
          Definition

          The Antepartum Education contains a list of patient education activities that have occured or have been planned to review with the patient.

          ShortAntepartumEducation
          Control0..1
          178. Composition.section:AntepartumEducation.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "34895-3"
            }]
          }
          180. Composition.section:AntepartumEducation.entry
          TypeReference(Procedure, Pregnancy Education Observation, Observation, DocumentReference)
          182. Composition.section:Payors
          Slice NamePayors
          Definition

          The Payers section contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination. .

          ShortPayors
          Control0..1
          184. Composition.section:Payors.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "48768-6"
            }]
          }
          186. Composition.section:Payors.entry
          TypeReference(Coverage)
          188. Composition.section:AntepartumVisitSummaryFlowsheet
          Slice NameAntepartumVisitSummaryFlowsheet
          Definition

          This section is a running history of the most important elements noted for a pregnant woman.

          ShortAntepartum Visit Summary Flowsheet
          Control0..1
          190. Composition.section:AntepartumVisitSummaryFlowsheet.code
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "57059-8"
            }]
          }
          192. Composition.section:AntepartumVisitSummaryFlowsheet.entry
          TypeReference(Observation, Antepartum Visit Summary Flowsheet Battery)