Profil für Composition
Link auf Simplifier: Das strukturierte Dokument
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https://tiplu.de/fhir/StructureDefinition/TipluStructuredDocument |
Definition
TipluStructuredDocument (Composition) | I | Composition | There are no (further) constraints on this element Element idComposition A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idComposition.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idComposition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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extension | I | 0..* | Extension | Element idComposition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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DocumentCompositionStatus | S I | 0..1 | Extension(code) | Element idComposition.extension:DocumentCompositionStatus Document Composition Status Alternate namesextensions, user content DefinitionDiese Extension erweitert Composition um die Status, die in HL7 FHIR R5 enthalten sind (https://hl7.org/fhir/r5/valueset-composition-status.html) There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://hl7.org/fhir/StructureDefinition/extension-Composition.status Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.status.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | Element idComposition.status.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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KundenCode | S I | 0..1 | Extension(Coding) | Element idComposition.status.extension:KundenCode Document Customer Status Alternate namesextensions, user content DefinitionDiese Extension erweitert Composition.status um die Möglichkeit einen individuellen Code zu hinterlegen There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. https://tiplu.de/fhir/StructureDefinition/DocumentCustomerStatus Constraints
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value | 0..1 | System.String | There are no (further) constraints on this element Element idComposition.status.value Primitive value for code DefinitionPrimitive value for code System.String Maximum string length1048576 | |
type | S Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.type Kind of composition (LOINC if possible) DefinitionSpecifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 2..* | Coding | Element idComposition.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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KDL | S Σ | 1..1 | CodingBinding | Element idComposition.type.coding:KDL Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. http://dvmd.de/fhir/ValueSet/kdl (required) Constraints
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IHE-TypeCode | S Σ | 1..1 | CodingBinding | Element idComposition.type.coding:IHE-TypeCode Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. http://dvmd.de/fhir/ConceptMap/kdl-ihe-typecode
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LOINC | S Σ | 0..1 | CodingBindingPattern | Element idComposition.type.coding:LOINC Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. DocumentTypeValueSet (required) Constraints
{ "system": "http://loinc.org" }
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TipluCode | S Σ | 0..1 | CodingBinding | Element idComposition.type.coding:TipluCode Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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category | S Σ | 1..* | CodeableConcept | There are no (further) constraints on this element Element idComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.category.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 1..* | Coding | Element idComposition.category.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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IHE-ClassCode | S Σ | 1..1 | CodingBinding | Element idComposition.category.coding:IHE-ClassCode Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. http://dvmd.de/fhir/ConceptMap/kdl-ihe-classcode
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LOINC | S Σ | 0..1 | CodingBindingPattern | Element idComposition.category.coding:LOINC Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. http://hl7.org/fhir/R4/valueset-document-classcodes.html (required) Constraints
{ "system": "http://loinc.org" }
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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subject | S Σ I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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encounter | S Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.date.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | Element idComposition.date.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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DocumentCreationDate | S I | 0..1 | Extension(dateTime) | Element idComposition.date.extension:DocumentCreationDate Document Creation Date Alternate namesextensions, user content DefinitionMit dieser Extension soll die Möglichkeit geboten werden, ein Erstelldatum an einer Composition zu hinterlegen. Benötigt wird das im Use Case eines strukturierten Dokumentes. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. https://tiplu.de/fhir/StructureDefinition/DocumentCreationDate Constraints
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value | 0..1 | System.DateTime | There are no (further) constraints on this element Element idComposition.date.value Primitive value for dateTime DefinitionPrimitive value for dateTime System.DateTime | |
author | S Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.author Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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title | S Σ | 1..1 | string | There are no (further) constraints on this element Element idComposition.title Human Readable name/title DefinitionOfficial human-readable label for the composition. For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition.
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attester | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.attester.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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mode | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. Note that FHIR strings SHALL NOT exceed 1MB in size The way in which a person authenticated a composition.
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time | 0..1 | dateTime | There are no (further) constraints on this element Element idComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
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party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints
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custodian | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
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relatesTo | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.relatesTo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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code | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents.
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target[x] | 1..1 | There are no (further) constraints on this element Element idComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | There are no (further) constraints on this element Data type | ||
targetReference | Reference(Composition) | There are no (further) constraints on this element Data type | ||
event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.event The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.event.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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code | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented.
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.section Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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title | S | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idComposition.section.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.code.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.code.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 1..* | Coding | Element idComposition.section.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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LOINC | S Σ | 0..1 | CodingBindingPattern | Element idComposition.section.code.coding:LOINC Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. DocumentSectionCodes (preferred) Constraints
{ "system": "http://loinc.org" }
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TipluCode | S Σ | 0..1 | CodingBinding | Element idComposition.section.code.coding:TipluCode Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. TipluDocumentSection (required) Constraints
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | S | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | S I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..* | see (section) | There are no (further) constraints on this element Element idComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Profilierungen
Type
Das Slicing von type.coding
umfasst vier verschiedene Teile:
- Das Binding auf die
KDL
(Simplifier-Projekt) - Das Binding auf den
IHE-TypeCode
http://ihe-d.de/ValueSets/IHEXDStypeCode
- Das Binding auf
LOINC
(http://hl7.org/fhir/ValueSet/c80-doc-typecodes
) - Das Binding auf das durch die Tiplu GmbH veröffentlichte CodeSystem
TipluDocumentType
. (https://tiplu.de/fhir/ValueSet/DocumentType
)
Category
Das Slicing von category.coding
umfasst zwei verschiedene Teile:
- Das Binding auf den
IHE-ClassCode
http://ihe-d.de/ValueSets/IHEXDSclassCode
- Das Binding auf
LOINC
(http://hl7.org/fhir/ValueSet/document-classcodes
)
Creation Date
Das Date wird mit der Extension https://tiplu.de/fhir/StructureDefinition/DocumentCreationDate
um die Möglichkeit erweitert, ein Erstelldatum anzugeben. Mehr dazu ist auf der Seite Extensions für Composition zu finden
Beispiel
{ "resourceType": "Composition", "id": "ExampleTipluDocument", "meta": { "profile": [ "https://tiplu.de/fhir/StructureDefinition/TipluStructuredDocument", "https://tiplu.de/fhir/StructureDefinition/TipluGeneralDocument" ] }, "identifier": { "system": "https://tiplu.de/fhir/identifier/documents", "value": "987321456852" }, "status": "preliminary", "type": { "coding": [ { "code": "EA01001", "system": "https://tiplu.de/fhir/CodeSystem/DocumentType" }, { "code": "AU010103", "system": "https://dvmd.de/fhir/CodeSystem/kdl" }, { "code": "AUFN", "system": "https://ihe-d.de/CodeSystems/IHEXDStypeCode" } ] }, "category": [ { "coding": [ { "code": "ADM", "system": "https://ihe-d.de/CodeSystems/IHEXDSclassCode" } ] } ], "subject": { "reference": "Patient/MusterPatient" }, "encounter": { "reference": "Encounter/MusterEncounter" }, "author": [ { "reference": "Organization/MusterOrganization" } ], "date": "2023-02-15T01:11:00+01:00", "_date": { "extension": [ { "url": "https://tiplu.de/fhir/StructureDefinition/DocumentCreationDate", "valueDateTime": "2023-02-15T01:11:00+01:00" } ] }, "title": "Entlassbrief", "section": [ { "title": "Anamnese", "code": { "coding": [ { "code": "Anamnese", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>Frau B. stellt sich vor mit ausgeprägter Atemnot bei vorbekannter COPD. Letztmalige Exazerbation vor 3 Monaten, Patientin in domo bekannt. Sie habe nach dem Aufstehen plötzlich keine Luft mehr bekommen. Außerdem verspürte Sie stärkstes dumpfe Stechen im Thorax. Ihr Notfallspray habe nicht geholfen und nach einigen Minuten habe sie dann den RTW gerufen. Sie habe auch starken Hustenreiz gehabt, auch mit Auswurf, das kenne sie aber von ihrer COPD. Keine Schmerzausstrahlung, kein thorakales Engegefühl, EKG im RTW unauffällig. Der Blutdruck habe zuhause bei 170/110 gelegen, das sei aber öfter so. Sonstige Beschwerden seien nicht vorhanden</div>" } }, { "title": "SozialeAnamnese", "code": { "coding": [ { "code": "SozialeAnamnese", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>Patientin ist Raucherin seit ca. 40 Jahren, sonst soweit fit, versorgt sich noch selbst, lebt mit ihrem Mann zusammen zu Hause. 2 Kinder, beide verheiratet. Familienanamnese: Mutter lebt noch, Vater mit 60 an „Herzanfall“ verstorben</div>" } }, { "title": "Medikamentenanamnese", "code": { "coding": [ { "code": "Medikamentenanamnese", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>Foster Inhal. 1-0-1 Salbutamol bei Bedarf Ramipril/HCT 5/25mg 1-0-1 Metoprolol 95mg 1-0-1 ASS 100 1-0-0 Simvastatin 40mg 1-0-0 Metformin 1000g 1-0-1 Lantus 14IE zur Nacht Tamoxifen (hat Pat. mit)</div>" } }, { "title": "Aufnahmebefunde", "code": { "coding": [ { "code": "Aufnahmebefunde", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>71j. Patientin in reduziertem AZ und adipösem EZ. Neurologisch grob unauffällig Cor: rein, rhythmisch, tachykard, 105/min, keine Strömungsgeräusche Pulmo: ubiquitär deutlich abgeschwächtes AG, links>rechts, Giemen, angestrengte Atmung, Perkussion unauffällig, keine mechanisch auslösbaren Schmerzen. Abdomen: weich, kein Druckschmerz, Darmgeräusche ubiquitär vorhanden. Unterschenkel geschwollen, Pat. habe wohl gelegentlich Ödeme. Puls 105/min, SpO2 90%, Temperatur 36,8°C, RR 160/100, AF 20/min</div>" } }, { "title": "Prozedere", "code": { "coding": [ { "code": "Prozedere", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>Stationäre Aufnahme BZTP Weiterführende Diagnostik (Echo, Sono, CT-Abdomen) nach Rücksprache Oberarzt Morgen Laborkontrolle: DifferentialBB, Elektrolyte, Leberwerte, Nierenwerte, HbA1c, Troponinkontrolle und erneute BGA in 3h</div>" } }, { "title": "Medikation", "code": { "coding": [ { "code": "Medikation", "system": "https://tiplu.de/fhir/CodeSystem/DocumentSection" } ] }, "text": { "status": "additional", "div": "<div>Hausmed. weiter, Unacid 1g 1-1-1, Clexane 0,4 0-0-1</div>" } } ] }