Composition

Resource name Canonical (defining) URL Simplifier link
Composition https://standards.medicalert.nz/ns/MaPatientSummaryComposition https://simplifier.net/nz-hira/medicalertcompositionips

The first entry in bundle will be a Composition resource, that has sections that are references to the Patient and all the patient's related clinical and administrative information.

Differential View

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS0..1Narrative
contained0..*Resource
versionNumberI0..1Extension(string)
MemberWarningStatus?! I1..1Extension(Coding)
identifierS Σ0..1Identifier
statusS Σ ?!1..1codeBinding
typeS Σ1..1Codeable Concept (IPS)BindingPattern
categoryΣ0..*CodeableConcept
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
dateS Σ1..1dateTime
authorS Σ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
titleS Σ1..1string
confidentialityΣ0..1codeBinding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
modeS1..1codeBinding
timeS0..1dateTime
partyS I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianS Σ I0..1Reference(Organization)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | Composition (IPS))
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeS Σ1..1CodeableConceptPattern
periodS Σ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title0..1string
codeS1..1Codeable Concept (IPS)
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
medicationStatementI0..*Reference(Medication Statement (IPS))
medicationRequestI0..*Reference(Medication Request (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
allergyOrIntoleranceS I1..*Reference(Allergy Intolerance (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
problemS I1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
procedureS I1..*Reference(Procedure (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
immunizationS I1..*Reference(Immunization (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
deviceStatementS I1..*Reference(Device Use Statement (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
results-observationS I0..*Reference(Observation Results (IPS))
results-diagnosticReportS I0..*Reference(DiagnosticReport (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
vitalSignI0..*Reference(Vital Signs Profile)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pastProblemI1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
disabilityI0..*Reference(Condition (IPS))
functionalAssessmentI0..*Reference(ClinicalImpression)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
carePlanI0..*Reference(CarePlan)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
smokingTobaccoUseI0..1Reference(Observation - SH: tobacco use)
alcoholUseI0..1Reference(Observation - SH: alcohol use)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pregnancyStatusI0..*Reference(Observation - Pregnancy: status)
pregnancyOutcomeSummaryI0..*Reference(Observation - Pregnancy: outcome)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
advanceDirectivesConsentI0..*Reference(Consent)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
warningS I1..*Reference(MedicAlert Warning)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
documentReferenceS I1..*Reference(MedicAlert DocumentReference)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)

Hybrid View

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS0..1Narrative
contained0..*Resource
versionNumberI0..1Extension(string)
MemberWarningStatus?! I1..1Extension(Coding)
identifierS Σ0..1Identifier
statusS Σ ?!1..1codeBinding
typeS Σ1..1Codeable Concept (IPS)BindingPattern
categoryΣ0..*CodeableConcept
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
dateS Σ1..1dateTime
authorS Σ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
titleS Σ1..1string
confidentialityΣ0..1codeBinding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
modeS1..1codeBinding
timeS0..1dateTime
partyS I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianS Σ I0..1Reference(Organization)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | Composition (IPS))
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeS Σ1..1CodeableConceptPattern
periodS Σ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title0..1string
codeS1..1Codeable Concept (IPS)
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
medicationStatementI0..*Reference(Medication Statement (IPS))
medicationRequestI0..*Reference(Medication Request (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
allergyOrIntoleranceS I1..*Reference(Allergy Intolerance (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
problemS I1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
procedureS I1..*Reference(Procedure (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
immunizationS I1..*Reference(Immunization (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
deviceStatementS I1..*Reference(Device Use Statement (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
results-observationS I0..*Reference(Observation Results (IPS))
results-diagnosticReportS I0..*Reference(DiagnosticReport (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
vitalSignI0..*Reference(Vital Signs Profile)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pastProblemI1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
disabilityI0..*Reference(Condition (IPS))
functionalAssessmentI0..*Reference(ClinicalImpression)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
carePlanI0..*Reference(CarePlan)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
smokingTobaccoUseI0..1Reference(Observation - SH: tobacco use)
alcoholUseI0..1Reference(Observation - SH: alcohol use)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pregnancyStatusI0..*Reference(Observation - Pregnancy: status)
pregnancyOutcomeSummaryI0..*Reference(Observation - Pregnancy: outcome)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
advanceDirectivesConsentI0..*Reference(Consent)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
warningS I1..*Reference(MedicAlert Warning)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
documentReferenceS I1..*Reference(MedicAlert DocumentReference)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)

Snapshot View

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS0..1Narrative
contained0..*Resource
versionNumberI0..1Extension(string)
MemberWarningStatus?! I1..1Extension(Coding)
identifierS Σ0..1Identifier
statusS Σ ?!1..1codeBinding
typeS Σ1..1Codeable Concept (IPS)BindingPattern
categoryΣ0..*CodeableConcept
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
dateS Σ1..1dateTime
authorS Σ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
titleS Σ1..1string
confidentialityΣ0..1codeBinding
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
modeS1..1codeBinding
timeS0..1dateTime
partyS I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianS Σ I0..1Reference(Organization)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | Composition (IPS))
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeS Σ1..1CodeableConceptPattern
periodS Σ I0..1Period
detailΣ I0..*Reference(Resource)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title0..1string
codeS1..1Codeable Concept (IPS)
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
medicationStatementI0..*Reference(Medication Statement (IPS))
medicationRequestI0..*Reference(Medication Request (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
allergyOrIntoleranceS I1..*Reference(Allergy Intolerance (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
problemS I1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
procedureS I1..*Reference(Procedure (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
immunizationS I1..*Reference(Immunization (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
deviceStatementS I1..*Reference(Device Use Statement (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
results-observationS I0..*Reference(Observation Results (IPS))
results-diagnosticReportS I0..*Reference(DiagnosticReport (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
vitalSignI0..*Reference(Vital Signs Profile)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pastProblemI1..*Reference(Condition (IPS))
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
disabilityI0..*Reference(Condition (IPS))
functionalAssessmentI0..*Reference(ClinicalImpression)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
carePlanI0..*Reference(CarePlan)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
smokingTobaccoUseI0..1Reference(Observation - SH: tobacco use)
alcoholUseI0..1Reference(Observation - SH: alcohol use)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
pregnancyStatusI0..*Reference(Observation - Pregnancy: status)
pregnancyOutcomeSummaryI0..*Reference(Observation - Pregnancy: outcome)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
title1..1string
code0..1CodeableConceptPattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
advanceDirectivesConsentI0..*Reference(Consent)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
warningS I1..*Reference(MedicAlert Warning)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
titleS1..1string
codeS1..1Codeable Concept (IPS)Pattern
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textS I1..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
documentReferenceS I1..*Reference(MedicAlert DocumentReference)
emptyReasonI0..0CodeableConceptBinding
sectionI0..0see (section)

Examples

Command 'pagelink' could not render: Page not found.

Detailed descriptions


Composition
DefinitionInternational Patient Summary composition. A composition is a set of healthcare-related information that is assembled together into a single logical document 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. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.
Cardinality0...*
Comments

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.

Invariants
  • dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    contained.contained.empty()
  • dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
  • dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
  • dom-6: A resource should have narrative for robust management
    text.`div`.exists()
  • dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    contained.meta.security.empty()
Mappings
  • rim: Entity. Role, or Act
  • workflow: Event
  • rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
  • cda: ClinicalDocument
  • fhirdocumentreference: when described by DocumentReference
Composition.id
DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Cardinality0...1
Typestring
SummaryTrue
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Composition.meta
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.
Cardinality0...1
TypeMeta
SummaryTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.implicitRules
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.
Cardinality0...1
Typeuri
ModifierTrue
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
Composition.language
DefinitionThe base language in which the resource is written.
Cardinality0...1
Typecode
Binding

A human language.

CommonLanguages (preferred)
Comments

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).

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
Composition.text
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.
Cardinality0...1
TypeNarrative
Must SupportTrue
Aliasnarrative, html, xhtml, display
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: Act.text?
Composition.contained
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.
Cardinality0...*
TypeResource
Aliasinline resources, anonymous resources, contained resources
Comments

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.

Mappings
  • rim: Entity. Role, or Act
  • rim: N/A
Composition.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.extension:versionNumber
DefinitionVersion specific identifier for the composition, assigned when each version is created/updated.
Cardinality0...1
TypeExtension(string)
Aliasextensions, user content
Comments

While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.modifierExtension
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).
Cardinality1...*
TypeExtension
ModifierTrue
Aliasextensions, user content
Requirements

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.

Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.modifierExtension:MemberWarningStatus
DefinitionModifierExtension for warnings about member status. The status may alter the interpretation, or warn about the currency or accuracy of information in the patient summary
Cardinality1...1
TypeExtension(Coding)
ModifierTrue
Aliasextensions, user content
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.identifier
DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Cardinality0...1
TypeIdentifier
Must SupportTrue
SummaryTrue
Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • workflow: Event.identifier
  • w5: FiveWs.identifier
  • rim: Document.id / Document.setId
  • cda: .setId
  • fhirdocumentreference: DocumentReference.masterIdentifier
Composition.status
DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
Cardinality1...1
Typecode
Binding

The workflow/clinical status of the composition.

CompositionStatus (required)
Must SupportTrue
ModifierTrue
SummaryTrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • workflow: Event.status
  • w5: FiveWs.status
  • rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
  • cda: n/a
  • fhirdocumentreference: DocumentReference.status
Composition.type
DefinitionSpecifies that this composition refers to a Patient Summary (Loinc "60591-5")
Cardinality1...1
TypeCodeable Concept (IPS)
Binding

Type of a composition.

FHIRDocumentTypeCodes (preferred)
Must SupportTrue
SummaryTrue
Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "60591-5"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • workflow: Event.code
  • w5: FiveWs.class
  • rim: ./code
  • cda: .code
  • fhirdocumentreference: DocumentReference.type
Composition.category
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.
Cardinality0...*
TypeCodeableConcept
Binding

High-level kind of a clinical document at a macro level.

DocumentClassValueSet (example)
SummaryTrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Comments

This is a metadata field from XDS/MHD.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • workflow: Event.subject
  • w5: FiveWs.class
  • rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
  • cda: n/a
  • fhirdocumentreference: DocumenttReference.category
Composition.subject
DefinitionWho or what the composition is about. In general a 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). For the IPS the subject is always the patient.
Cardinality1...1
TypeReference(Patient (IPS))
Must SupportTrue
SummaryTrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Comments

For clinical documents, this is usually the patient.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.subject[x]
  • rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
  • cda: .recordTarget
  • fhirdocumentreference: DocumentReference.subject
  • w5: FiveWs.subject
Composition.subject.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.subject.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.subject.reference
DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Cardinality1...1
Typestring
Must SupportTrue
SummaryTrue
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.subject.type
DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Cardinality0...1
Typeuri
Binding

Aa resource (or, for logical models, the URI of the logical model).

ResourceType (extensible)
SummaryTrue
Comments

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.subject.identifier
DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Cardinality0...1
TypeIdentifier
SummaryTrue
Comments

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.subject.display
DefinitionPlain text narrative that identifies the resource in addition to the resource reference.
Cardinality0...1
Typestring
SummaryTrue
Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.encounter
DefinitionDescribes the clinical encounter or type of care this documentation is associated with.
Cardinality0...1
TypeReference(Encounter)
SummaryTrue
Requirements

Provides context for the composition and supports searching.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow: Event.context
  • w5: FiveWs.context
  • rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
  • cda: .componentOf.encompassingEncounter
  • fhirdocumentreference: DocumentReference.context.encounter
Composition.date
DefinitionThe composition editing time, when the composition was last logically changed by the author.
Cardinality1...1
TypedateTime
Must SupportTrue
SummaryTrue
Requirements

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.

Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • workflow: Event.occurrence[x]
  • w5: FiveWs.done[x]
  • rim: .effectiveTime[type="TS"]
  • cda: .effectiveTime
  • fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created
Composition.author
DefinitionIdentifies who is responsible for the information in the IPS, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" IPS Vs. an "automatically generated" IPS.
Cardinality1...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Must SupportTrue
SummaryTrue
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow: Event.performer
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
  • fhirdocumentreference: DocumentReference.agent
Composition.title
DefinitionOfficial human-readable label for the composition. For this document should be "International Patient Summary" or any equivalent translation
Cardinality1...1
Typestring
Must SupportTrue
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
  • fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title
Composition.confidentiality
DefinitionThe code specifying the level of confidentiality of the Composition.
Cardinality0...1
Typecode
Binding

Codes specifying the level of confidentiality of the composition.

v3.ConfidentialityClassification (required)
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .confidentialityCode
  • cda: .confidentialityCode
  • fhirdocumentreference: DocumentReference.securityLabel
Composition.attester
DefinitionA participant who has attested to the accuracy of the composition/document.
Cardinality0...*
TypeBackboneElement
Must SupportTrue
Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
  • cda: .authenticator/.legalAuthenticator
  • fhirdocumentreference: DocumentReference.authenticator
Composition.attester.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.attester.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.attester.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.attester.mode
DefinitionThe type of attestation the authenticator offers.
Cardinality1...1
Typecode
Binding

The way in which a person authenticated a composition.

CompositionAttestationMode (required)
Must SupportTrue
Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: unique(./modeCode)
  • cda: implied by .authenticator/.legalAuthenticator
Composition.attester.time
DefinitionWhen the composition was attested by the party.
Cardinality0...1
TypedateTime
Must SupportTrue
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./time[type="TS" and isNormalDatatype()]
  • cda: .authenticator.time
Composition.attester.party
DefinitionWho attested the composition in the specified way.
Cardinality0...1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
Must SupportTrue
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.witness
  • rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
  • cda: .authenticator.assignedEnttty
Composition.custodian
DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
Cardinality0...1
TypeReference(Organization)
Must SupportTrue
SummaryTrue
Requirements

Identifies where to go to find the current version, where to report issues, etc.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
  • cda: .custodian.assignedCustodian
  • fhirdocumentreference: DocumentReference.custodian
Composition.relatesTo
DefinitionRelationships that this composition has with other compositions or documents that already exist.
Cardinality0...*
TypeBackboneElement
Comments

A document is a version specific composition.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outboundRelationship
  • cda: .relatedDocument
  • fhirdocumentreference: DocumentReference.relatesTo
Composition.relatesTo.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.relatesTo.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.relatesTo.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.relatesTo.code
DefinitionThe type of relationship that this composition has with anther composition or document.
Cardinality1...1
Typecode
Binding

The type of relationship between documents.

DocumentRelationshipType (required)
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outboundRelationship.typeCode
  • cda: .relatedDocument.typeCode
  • fhirdocumentreference: DocumentReference.relatesTo.code
Composition.relatesTo.target[x]
DefinitionThe target composition/document of this relationship.
Cardinality1...1
TypeIdentifier
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .target[classCode="DOC", moodCode="EVN"].id
  • cda: .relatedDocument.id
  • fhirdocumentreference: DocumentReference.relatesTo.target
Composition.event
DefinitionThe main activity being described by a IPS is the provision of healthcare over a period of time. In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the IPS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.
Cardinality0...*
TypeBackboneElement
SummaryTrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

SlicingUnordered, Open, by code(Pattern)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
  • cda: .documentationOf.serviceEvent
  • fhirdocumentreference: DocumentReference.event
Composition.event.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.event.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event.code
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.
Cardinality0...*
TypeCodeableConcept
Binding

This list of codes represents the main clinical acts being documented.

v3.ActCode (example)
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .code
  • cda: .code
  • fhirdocumentreference: DocumentReference.event.code
Composition.event.period
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.
Cardinality0...1
TypePeriod
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • per-1: If present, start SHALL have a lower value than end
    start.hasValue().not() or end.hasValue().not() or (start <= end)
Mappings
  • rim: n/a
  • v2: DR
  • rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
  • rim: .effectiveTime
  • cda: .effectiveTime
  • fhirdocumentreference: DocumentReference.event.period
Composition.event.detail
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.
Cardinality0...*
TypeReference(Resource)
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode="SUBJ"].target
  • cda: n/a
Composition.event:careProvisioningEvent
DefinitionThe provision of healthcare over a period of time this IPS is documenting.
Cardinality0...1
TypeBackboneElement
Must SupportTrue
SummaryTrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
  • cda: .documentationOf.serviceEvent
  • fhirdocumentreference: DocumentReference.event
Composition.event:careProvisioningEvent.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.event:careProvisioningEvent.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event:careProvisioningEvent.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event:careProvisioningEvent.code
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.
Cardinality1...1
TypeCodeableConcept
Binding

This list of codes represents the main clinical acts being documented.

v3.ActCode (example)
Must SupportTrue
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass",
      "code": "PCPR"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .code
  • cda: .code
  • fhirdocumentreference: DocumentReference.event.code
Composition.event:careProvisioningEvent.period
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.
Cardinality0...1
TypePeriod
Must SupportTrue
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • per-1: If present, start SHALL have a lower value than end
    start.hasValue().not() or end.hasValue().not() or (start <= end)
Mappings
  • rim: n/a
  • v2: DR
  • rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
  • rim: .effectiveTime
  • cda: .effectiveTime
  • fhirdocumentreference: DocumentReference.event.period
Composition.event:careProvisioningEvent.detail
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.
Cardinality0...*
TypeReference(Resource)
SummaryTrue
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode="SUBJ"].target
  • cda: n/a
Composition.section
DefinitionThe root of the sections that make up the IPS composition.
Cardinality3...*
TypeBackboneElement
Must SupportTrue
SlicingUnordered, Open, by code(Pattern)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section.title
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.
Cardinality0...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section.code
DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.
Cardinality1...1
TypeCodeable Concept (IPS)
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Must SupportTrue
Requirements

Provides computable standardized labels to topics within the document.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section.text
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.
Cardinality1...1
TypeNarrative
Must SupportTrue
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section.entry
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section.section
DefinitionA nested sub-section within this section.
Cardinality0...0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionMedications
DefinitionThe medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report: - the currently active medications; - the current and past medications considered relevant by the authoring GP; - the patient prescriptions or dispensations automatically extracted by a regional or a national EHR. In those cases medications are documented in the Patient Summary as medication statements or medication requests. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.
Cardinality1...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionMedications.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionMedications.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionMedications.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionMedications.title
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. Medication Summary
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionMedications.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10160-0"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionMedications.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionMedications.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionMedications.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionMedications.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionMedications.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionMedications.entry
DefinitionThis list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication; either that no information is available about medications.
Cardinality1...*
TypeReference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionMedications.entry:medicationStatement
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Medication Statement (IPS))
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionMedications.entry:medicationRequest
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Medication Request (IPS))
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionMedications.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionMedications.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionAllergies
DefinitionThis section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
Cardinality1...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionAllergies.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionAllergies.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionAllergies.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionAllergies.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionAllergies.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "48765-2"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionAllergies.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionAllergies.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionAllergies.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionAllergies.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionAllergies.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionAllergies.entry
DefinitionIt lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known .
Cardinality1...*
TypeReference(AllergyIntolerance | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionAllergies.entry:allergyOrIntolerance
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Allergy Intolerance (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionAllergies.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionAllergies.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionProblems
DefinitionThe IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
Cardinality1...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionProblems.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionProblems.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionProblems.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionProblems.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionProblems.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11450-4"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionProblems.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionProblems.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionProblems.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionProblems.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionProblems.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionProblems.entry
DefinitionIt lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known.
Cardinality1...*
TypeReference(Condition | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionProblems.entry:problem
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Condition (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionProblems.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionProblems.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionProceduresHx
DefinitionThe History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionProceduresHx.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionProceduresHx.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionProceduresHx.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionProceduresHx.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionProceduresHx.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47519-4"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionProceduresHx.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionProceduresHx.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionProceduresHx.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionProceduresHx.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionProceduresHx.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionProceduresHx.entry
DefinitionIt lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to: 1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section) 2. Therapeutic procedure: e.g. dialysis; 3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.
Cardinality1...*
TypeReference(Procedure | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionProceduresHx.entry:procedure
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Procedure (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionProceduresHx.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionProceduresHx.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionImmunizations
DefinitionThe Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionImmunizations.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionImmunizations.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionImmunizations.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionImmunizations.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionImmunizations.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11369-6"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionImmunizations.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionImmunizations.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionImmunizations.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionImmunizations.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionImmunizations.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionImmunizations.entry
DefinitionIt defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.
Cardinality1...*
TypeReference(Immunization | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionImmunizations.entry:immunization
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Immunization (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionImmunizations.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionImmunizations.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionMedicalDevices
DefinitionThe medical devices section contains narrative text and coded entries describing the patient history of medical device use.
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionMedicalDevices.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionMedicalDevices.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionMedicalDevices.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionMedicalDevices.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionMedicalDevices.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46264-8"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionMedicalDevices.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionMedicalDevices.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionMedicalDevices.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionMedicalDevices.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionMedicalDevices.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionMedicalDevices.entry
DefinitionIt describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known.
Cardinality1...*
TypeReference(DeviceUseStatement | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionMedicalDevices.entry:deviceStatement
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Device Use Statement (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionMedicalDevices.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionMedicalDevices.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionResults
DefinitionThis section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionResults.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionResults.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionResults.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionResults.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionResults.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "30954-2"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionResults.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionResults.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionResults.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionResults.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionResults.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionResults.entry
DefinitionRelevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
Cardinality1...*
TypeReference(Observation | DiagnosticReport | DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Type), resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionResults.entry:results-observation
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Observation Results (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionResults.entry:results-diagnosticReport
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(DiagnosticReport (IPS))
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionResults.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionResults.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionVitalSigns
DefinitionThe Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionVitalSigns.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionVitalSigns.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionVitalSigns.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionVitalSigns.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionVitalSigns.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8716-3"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionVitalSigns.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionVitalSigns.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionVitalSigns.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionVitalSigns.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionVitalSigns.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionVitalSigns.entry
DefinitionNotable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
Cardinality0...*
TypeReference(Observation | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionVitalSigns.entry:vitalSign
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Vital Signs Profile)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionVitalSigns.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionVitalSigns.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionPastIllnessHx
DefinitionThe History of Past Illness section contains a description of the conditions the patient suffered in the past.
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionPastIllnessHx.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionPastIllnessHx.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPastIllnessHx.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPastIllnessHx.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionPastIllnessHx.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11348-0"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionPastIllnessHx.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionPastIllnessHx.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionPastIllnessHx.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionPastIllnessHx.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionPastIllnessHx.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionPastIllnessHx.entry
DefinitionIt contains a description of the conditions the patient suffered in the past.
Cardinality1...*
TypeReference(Condition | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPastIllnessHx.entry:pastProblem
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(Condition (IPS))
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPastIllnessHx.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionPastIllnessHx.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionFunctionalStatus
DefinitionThe functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionFunctionalStatus.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionFunctionalStatus.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionFunctionalStatus.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionFunctionalStatus.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionFunctionalStatus.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47420-5"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionFunctionalStatus.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionFunctionalStatus.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionFunctionalStatus.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionFunctionalStatus.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionFunctionalStatus.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionFunctionalStatus.entry
DefinitionIt describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
Cardinality0...*
TypeReference(Condition | ClinicalImpression | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionFunctionalStatus.entry:disability
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Condition (IPS))
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionFunctionalStatus.entry:functionalAssessment
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(ClinicalImpression)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionFunctionalStatus.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionFunctionalStatus.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionPlanOfCare
DefinitionThe plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionPlanOfCare.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionPlanOfCare.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPlanOfCare.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPlanOfCare.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionPlanOfCare.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18776-5"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionPlanOfCare.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionPlanOfCare.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionPlanOfCare.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionPlanOfCare.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionPlanOfCare.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionPlanOfCare.entry
DefinitionDynamic, personalized plan including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process [Source EN ISO 13940]
Cardinality0...*
TypeReference(CarePlan | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPlanOfCare.entry:carePlan
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(CarePlan)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPlanOfCare.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionPlanOfCare.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionSocialHistory
DefinitionThe social history section contains a description of the person’s Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionSocialHistory.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionSocialHistory.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionSocialHistory.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionSocialHistory.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionSocialHistory.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29762-2"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionSocialHistory.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionSocialHistory.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionSocialHistory.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionSocialHistory.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionSocialHistory.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionSocialHistory.entry
DefinitionDescription of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Cardinality0...*
TypeReference(Observation | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionSocialHistory.entry:smokingTobaccoUse
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...1
TypeReference(Observation - SH: tobacco use)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionSocialHistory.entry:alcoholUse
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...1
TypeReference(Observation - SH: alcohol use)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionSocialHistory.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionSocialHistory.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionPregnancyHx
DefinitionThe history of pregnancy section shall contain information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionPregnancyHx.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionPregnancyHx.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPregnancyHx.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionPregnancyHx.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionPregnancyHx.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10162-6"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionPregnancyHx.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionPregnancyHx.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionPregnancyHx.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionPregnancyHx.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionPregnancyHx.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionPregnancyHx.entry
DefinitionIt contains information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.
Cardinality0...*
TypeReference(Observation | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPregnancyHx.entry:pregnancyStatus
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Observation - Pregnancy: status)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Observation - Pregnancy: outcome)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionPregnancyHx.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionPregnancyHx.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionAdvanceDirectives
DefinitionThe advance directives section contains a narrative description of patient's advance directive.
Cardinality0...1
TypeBackboneElement
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionAdvanceDirectives.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionAdvanceDirectives.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionAdvanceDirectives.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionAdvanceDirectives.title
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.
Cardinality1...1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionAdvanceDirectives.code
DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title.
Cardinality0...1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Requirements

Provides computable standardized labels to topics within the document.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "42348-3"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionAdvanceDirectives.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionAdvanceDirectives.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionAdvanceDirectives.text
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.
Cardinality0...1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionAdvanceDirectives.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionAdvanceDirectives.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionAdvanceDirectives.entry
DefinitionContains a narrative description or a Consent entry with information about the patient's advance directive.
Cardinality0...*
TypeReference(Consent | DocumentReference)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality0...*
TypeReference(Consent)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionAdvanceDirectives.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionAdvanceDirectives.section
DefinitionA nested sub-section within this section.
Cardinality0...*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionWarnings
DefinitionWarnings that MedicAlert holds for a patient that do not fit into other resources in the patient summary or to highlight important resources within the summary.
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionWarnings.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionWarnings.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionWarnings.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionWarnings.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionWarnings.code
DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.
Cardinality1...1
TypeCodeable Concept (IPS)
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Must SupportTrue
Requirements

Provides computable standardized labels to topics within the document.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "74018-3"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionWarnings.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionWarnings.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionWarnings.text
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.
Cardinality1...1
TypeNarrative
Must SupportTrue
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionWarnings.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionWarnings.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionWarnings.entry
DefinitionWarnings that MedicAlert holds for a patient that do not fit into other resources in the patient summary or to highlight important resources within the summary
Cardinality1...*
TypeReference(Flag)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionWarnings.entry:warning
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(MedicAlert Warning)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionWarnings.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionWarnings.section
DefinitionA nested sub-section within this section.
Cardinality0...0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:sectionDocuments
Definitionused to link resources (such as Advance Directives and Emergency medical action plans) to a copy of the original document (in PDF format).
Cardinality0...1
TypeBackboneElement
Must SupportTrue
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • cmp-1: A section must contain at least one of text, entries, or sub-sections
    text.exists() or entry.exists() or section.exists()
  • cmp-2: A section can only have an emptyReason if it is empty
    emptyReason.empty() or entry.empty()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:sectionDocuments.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
Typestring
Mappings
  • rim: n/a
Composition.section:sectionDocuments.extension
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.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

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.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionDocuments.modifierExtension
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).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

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.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:sectionDocuments.title
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.
Cardinality1...1
Typestring
Must SupportTrue
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:sectionDocuments.code
DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.
Cardinality1...1
TypeCodeable Concept (IPS)
Binding

Classification of a section of a composition/document.

DocumentSectionCodes (example)
Must SupportTrue
Requirements

Provides computable standardized labels to topics within the document.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "42348-3"
    }
  ]
}

Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:sectionDocuments.author
DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in.
Cardinality0...*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.author
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
Composition.section:sectionDocuments.focus
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).
Cardinality0...1
TypeReference(Resource)
Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • cda: .subject? (CDA did not differentiate between subject and focus)
Composition.section:sectionDocuments.text
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.
Cardinality1...1
TypeNarrative
Must SupportTrue
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:sectionDocuments.mode
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.
Cardinality0...1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.class
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
Composition.section:sectionDocuments.orderedBy
DefinitionSpecifies the order applied to the items in the section entries.
Cardinality0...1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:sectionDocuments.entry
Definitionused to link resources (such as Advance Directives and Emergency medical action plans) to a copy of the original document (in PDF format)
Cardinality1...*
TypeReference(DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

SlicingUnordered, Open, by resolve()(Profile)
Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionDocuments.entry:documentReference
DefinitionA reference to the actual resource from which the narrative in the section is derived.
Cardinality1...*
TypeReference(MedicAlert DocumentReference)
Must SupportTrue
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:sectionDocuments.emptyReason
DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Cardinality0...0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

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.

Invariants
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
  • cda: n/a
Composition.section:sectionDocuments.section
DefinitionA nested sub-section within this section.
Cardinality0...0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section