Name Flags Card. Type Description & Constraints doco
. . Composition 0 .. *
. . . type 1 .. 1 CodeableConcept History and Physical
Binding: HPDocumentType (required)
. . . section BackboneElement Slice: Unordered, Open by value:code
. . . section 1..1 BackboneElement Allergies and Intolerances Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Allergies, adverse reactions, alerts
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core AllergyIntolerance Profile)
. . . section 1..1 BackboneElement Family History Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Family History
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10157-6"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core AllergyIntolerance Profile)
. . . section 1..1 BackboneElement General Status Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept General Status
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10210-3"}]}
. . . . text 1..1 Narrative text
. . . section 1..1 BackboneElement History of Past Illness Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept History of Past Illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]}
. . . . text 1..1 Narrative text
. . . section 1..1 BackboneElement Medications Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept History of medication use
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core MedicationStatement Profile)
. . . section 1..1 BackboneElement Physical Exam Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Physical Findings
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29545-1"}]}
. . . . text 1..1 Narrative text
. . . section 1..1 BackboneElement Results Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Relevant diagnostic tests and/or laboratory data
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Results Profile)
. . . section 1..1 BackboneElement Review of Systems Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Review of Systems
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10187-3"}]}
. . . . text 1..1 Narrative text
. . . section 1..1 BackboneElement Social History Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Social History
Required Pattern: {"coding":[{"code":"29762-2"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Smoking Status Profile)
. . . section 1..1 BackboneElement Vital Signs Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Vital Signs
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(VitalSigns)
. . . section 0..1 BackboneElement History of Present Illness Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept History of Present Illness
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10164-2"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Assessment and Plan Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Assessment and Plan
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51847-2"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Assessment Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Assessments
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"51848-0"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Chief Complaint and Reason for Visit Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Chief Complaint and Reason for Visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"46239-0"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Chief Complaint Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Chief Complaint
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"10154-3"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Immunizations Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Immunizations
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Immunization Profile)
. . . section 0..1 BackboneElement Plan of Treatment Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Plan of Treatment
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Goal Profile), Reference(US Core MedicationRequest Profile), Reference(Communication), Reference(Appointment), Reference(CommunicationRequest), Reference(DeviceRequest), Reference(NutritionOrder), Reference(Task), Reference(ProcedureRequest), Reference(VisionPrescription), Reference(RequestGroup)
. . . section 0..1 BackboneElement Problem Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Problem List
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Condition (a.k.a Problem) Profile)
. . . section 0..1 BackboneElement Procedures Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept History of Procedures
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]}
. . . . text 1..1 Narrative text
. . . . entry Reference ( Resource ) entry
Slice: Unordered, Open by profile:reference
. . . . entry 0 .. * Reference(US Core Procedure Profile)
. . . section 0..1 BackboneElement Reason for Visit Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Reason for Visit
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"29299-5"}]}
. . . . text 1..1 Narrative text
. . . section 0..1 BackboneElement Instructions Section
. . . . title 1..1 string title
. . . . code 1..1 CodeableConcept Instructions
Required Pattern: {"coding":[{"system":"http://loinc.org","code":"69730-0"}]}
. . . . text 1..1 Narrative text

doco Documentation for this format